An entire continent in need of cheap medicines
The price of medicines in many low- and middle-income countries, especially in Africa, can be 20-30 times the international reference price for generics; this is true even for basic products such as paracetamol (1). The problem is blamed on inconsistent and inefficient healthcare systems, but also on disorganised demand, logistical issues and supply chains focused on cities to the detriment of rural areas.
Organisations like Médecins Sans Frontières (MSF) also blame manufacturers’ pricing policies. MSF wants multinational Johnson & Johnson (J&J) to make its tuberculosis drug Bedaquiline available for $1 per day ($180 for a six-month course of treatment). In low- and middle-income countries J&J currently charges $400 for a six-month course, putting it ‘out of reach for more than 80% of people who need it to stay alive’ (2). This July, J&J compromised, agreeing to $1.50 per day, but MSF believes the price should reflect the government subsidies that went into to its development, and the role that the scientific community and NGOs play in the fight against drug-resistant TB.
The distribution of medicines in the private sector (which provides 80% of healthcare in middle-income countries) differs according to country. In Africa’s French-speaking countries, sales prices are regulated, and wholesale distributors handle supply; they procure medicines from manufacturers, and are required to supply dispensaries with the full range of authorised drugs, and deliver on a regular basis. In Africa’s English-speaking countries, manufacturers appoint a sole agent to import medicines, which are then sold on to large numbers of businesses, which in turn sell them on to retailers. These are not necessarily pharmacies: ‘In French-speaking African countries, as in France, you will find the same drugs in the same package, at the same price, everywhere. In English-speaking countries, prices are unregulated,’ said Jean-Marc Leccia, CEO of French distributor Eurapharma (now owned by Japanese carmaker Toyota), which controls 40% of the West African supply network.
Price liberalisation has less impact where private donors cover half of all public-sector healthcare spending, as is the case in the 24 low-income countries in Sub-Saharan Africa. The Global Fund to Fight AIDS, Tuberculosis and Malaria (which spends at least $1bn a year on health products) acts as a powerful central purchasing organisation, able to negotiate simultaneously with the eight suppliers who share the market between them. But negotiations are tricky even between the pharmaceutical industry and major humanitarian organisations: manufacturers want to protect their profit margins, and the volume they sell. The less widely used treatments, such as paediatric drugs for HIV (which is declining among mothers and consequently among children) and concurrent administration of the antimalarials artesunate and mefloquine (necessary only in the Mekong valley), interest them only if the prices are high.
Even where demand exists, it does not always determine the price charged. ‘The way manufacturers set prices has nothing to do with the number of people who need the drug,’ said Gaëlle Krikorian, head of policy for MSF’s drug access campaign. ‘They try to strike a balance between the number of people who have enough money to pay for the drug, and the kind of price it’s possible to charge them.’ US pharmaceutical giant Gilead, making judicious use of licensing, charges several thousand dollars for its hepatitis C treatments in middle-income countries such as Morocco, where they are only accessible to a small proportion of the hundreds of thousands of people who need them. Manufacturers, including even generics firms, have no interest in older treatments, which are easier to make and less profitable: besides penicillin, these include painkillers, which are neglected in most of the poorest African countries. Morphine, which is subject to international regulation but cheap to make in oral forms, is virtually unobtainable in most African countries, whereas the imported injectable forms, more costly to make, are available on the private market.
In May 2019 the World Health Assembly adopted a resolution calling for greater transparency on actual prices paid by governments and health product buyers, and on the results of clinical trials (3). Krikorian said, ‘A very interesting coalition of countries from the North and South came together to say, “We must have transparency; we want to know how much people are paying, who pays for what, and how much it costs”.’ With the backing of NGOs, South Africa and Uganda campaigned for the adoption of the resolution; Germany (which proposed 25 amendments) and the UK opposed it.
Séverine Charon & Laurence Soustras
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