Availability of cardiovascular medicines varied considerably across the surveyed countries, even within income groups. Availabilities ranging from 0 to 100% within one income group were no exception (tables and ).
Public sector percentage availability by World Bank income group (weighted averages).
Private sector percentage availability by World Bank income group (weighted averages).
Overall, atenolol 50 mg had the highest availability for the lowest-priced generic (LPG) in both the public and private sectors (38.9% and 73.3% respectively) and losartan the lowest. The entire basket of cardiovascular medicines had an average availability of 26.3% for the LPG in the public sector and 57.3% in the private sector (LPG). For all medicines, the private sector had better availability than the public sector, both for LPGs and originator brand products (OB).
In nearly all surveys, LPGs had a higher availability than originator brand products. The only exception to this was losartan, which is still under patent; ten out of thirty surveys had better availability of the OB. Across income groups, in both the public and private sector, higher income regions tended to have better availability than lower income regions. In the private sector, higher income areas with a low availability of LPGs had a high availability of OBs.
Public sector procurement prices
A comparison of public sector procurement prices showed that they varied greatly both across medicines and countries/regions. For example, the CPI-adjusted MPR for captopril was 0.21 in Peru and the United Arab Emirates and 12.75 in Morocco. This means that prices ranged from 0.21 to 12.75 times the international reference price. The average procurement MPR for both generic and originator products are summarized in Figure . It is important to realize that MPR is a measure relative to the international reference price, not an absolute measure. This may explain the high MPR for hydrochlorothiazide. There was no data available concerning the procurement of originator brand hydrochlorothiazide.
Figure 1 Procurement MPRs (CPI adjusted) for the LPG and the OB. The line represents a price ratio equal to 1.0 (procurement at the same price as the international reference price). Abbreviations: HCT - hydrochlorothiazide; LPG - lowest-priced generic; OB - originator (more ...)
No particular relationship could be found across World Bank Income Groups. Nigeria and Mongolia had the highest procurement prices for several medicines. Some countries were capable of obtaining consistently low procurement prices, in particular Ethiopia, Fiji and Jordan.
Data matched by medicine, which allow for comparison of procurement prices and public sector patient prices within one survey, were only available for a very limited number of surveys and medicines (data not shown). It could be seen that in Ethiopia and Tanzania patient prices were at least 50% more expensive than the procurement price for three out of four medicines. On the other hand, patient prices were lower than procurement prices for several medicines in Nigeria.
Figure summarizes the average median price ratios for the LPG and the OB in the public and private sector. Data classified by income group is presented in tables and .
Average CPI and PPP adjusted MPRs for atenolol, captopril, hydrochlorothiazide and nifedipine. Abbreviations: HCT - hydrochlorothiazide; LPG - lowest priced generic; OB - originator brand; MPR - Median Price Ratio.
Public sector patient MPR (CPI and PPP adjusted), by World Bank income group (weighted averages).
Private sector patient MPR (CPI and PPP adjusted), by World Bank income group (weighted averages).
Across the cardiovascular medicines, captopril (LPG) had the lowest MPR in both the public and private sector. The highest MPR was found for hydrochlorothiazide. When comparing the public and private sector, it can be seen that for LPGs, the private sector was on average more expensive for all medicines. Importantly, countries that provide medicines for free in the public sector were not included to calculate the average MPR. For originator brand products, a direct comparison between the public and private sector could not be made due to the very limited availability of OB products in the public sector.
Lower income countries (LI and LMI) tended to have higher adjusted prices than the upper income countries (UMI and HI), both in the public and private sector. Again, some countries had consistently high or low prices across multiple medicines. High prices were found in El-Salvador and the Philippines, while low prices were often found in Fiji and Yemen.
Brand premiums were calculated when possible; there was insufficient data available to calculate brand premiums in the public sector due to the low availability of OB products. Results are presented in figure . It was found that on average, brand premiums were lower in higher income countries as compared to lower income areas. Countries with high brand premiums for multiple medicines were Fiji and Peru, while low brand premiums could often be found in El-Salvador, Kuwait and the UAE.
Brand premiums in the private sector, by medicine and World Bank income group. Abbreviations: LI - low income; LMI - lower-middle income; UMI - upper-middle income; HI - high income, Capt - captopril.
Data for affordability were limited, in particular in the public sector; for losartan and nifedipine data were only available from two and three surveys, respectively. Therefore, the results may not always be representative of the entire sample.
In the public sector (n = 28, from 18 countries/regions), it cost on average 2.0 (LPG) and 8.3 (OB) day's wages to purchase one month of treatment with one of the cardiovascular medicines. On average affordability was better in the private sector (1.8 and 5.3 day's wages for the LPG and OB). When countries were matched, however, the private sector was usually less affordable than the public sector. Atenolol was most affordable, with an average of 1.1 day's wages for the LPG. When matched across surveys, the LPG was in all cases more affordable than the OB product, both in the public and private sector. Overall, cardiovascular medicines were least affordable in the low income regions. Upper-middle income countries scored particularly well, especially when compared to high income regions.