El-Dahiyat, Faris Abdelrahim (2013) A cost evaluation analysis to identify solutions for affordable medicines in Jordan : a comparative study with the UK. (PhD thesis), Kingston University, .
Abstract
Background: Health is a core human right. The right of health care includes access to affordable medicines. Affordability of medicines by individual patients in low-income countries is a significant factor influencing access to care and treatment. However, drug prices in low income countries are found to be higher than those in high-income countries. Although the health care system in Jordan is quite advanced in comparison to neighbouring countries, the access to affordable medicines remains problematic. It was reported that almost 80% of the public in Jordan pay for their medications through out-of-pocket payments. High medicine prices are of a great concern to patients and their finances, which can result in poor compliance. Moreover, non-compliance can lead to reduced productivity and increased medical costs. In fact, several studies found that the high out of pocket-costs can be a significant obstacle to medical adherence with prescription medication regimens. Aims: The aim of this thesis is to research medicine prices and policies in Jordan, in order to recommend feasible solutions to make these affordable. To measure the affordability of medicines in Jordan and to assess the extent by which the cost of medicines is high, prices and factors affecting them were compared with the United Kingdom (UK), a high income developed country. Methods: A mixed-method approach was used in this thesis to research medicine prices and policies. The thesis reviewed the relevant literature, followed by reviewing the health care and pharmaceutical systems in both countries and their impact on medicine prices. Quantitative studies to measure the affordability of medicines in Jordan were conducted to assess the extent by which the cost of medicines is high in comparison to the UK and the factors that may affect medicine prices. This was followed by a qualitative study on how and why high unaffordable prices occur in Jordan. Finally, a quantitative survey exploring patients', pharmacists' and prescribing physicians' opinions towards measures that could be used to achieve greater clinical effectiveness and economic efficiency from drug prescribing was conducted. All the findings from the thesis were synthesised to form policy recommendations, designed to ensure affordable medicines for the Jordanian population. Results and discussion: Factors that influence prices of medicines over time were identified. These included; competition, marketing strategies, time in the market, regulations and pricing policy, change of clinical guidelines, epidemiology of disease, change in therapeutic use/value and exchange rate. Although the income per capita is much lower in Jordan (almost 7 fold less) than the one the UK, the studies conducted within this thesis demonstrated that medicine prices were significantly higher in Jordan compared to the UK. Generic medicines are three fold more expensive than the equivalent prices of the same drugs in the UK. However, the difference in prices for many drugs was significantly higher than the 3 fold difference. For example, the average price of pravastatin and amlodipine generics was more than eight fold higher than the UK price. Moreover, the average price of omeprazole, citalopram and fluoxetine generics were around 10 fold higher than the comparable UK price. Additionally, originator brand medicines prices were also found to be 1.5-fold more expensive in Jordan compared to the UK. Many originators were extremely higher than this average. For example, the Jordanian price of misoprostol originator tablets was around 19 times the comparable UK price. The price of ranitidine originator in Jordan was more than seven times the UK price and lansoprasole originator was around 6 times more than the price in the UK. The current pricing policy and its application are believed to be the root causes for the high prices of medicines in Jordan, as revealed by the qualitative interviews. The expected patients' saving by using generic medicines instead of originators in Jordan ranged from 32% up to 74%. The median saving in Jordan was -30.65% compared to - 71.43% in UK. The average savings were 32.68% and 43.54% in both Jordan and UK respectively. This increased to 54.96% in the UK when one outlier was removed. However, the saving calculated in both countries would have been higher if the lowest priced generic was used. An extra saving of 6.86% was identified in Jordan if the lowest priced generics were used for cardiovascular diseases (the calculated saving increased from 32.71% when using the average generic price compared to 39.57% when using the lowest priced generic). The findings also showed a positive attitude of all stakeholders (patients, pharmacists and prescribing physicians) towards generic medications and their willingness and acceptance of strategies that encourage generic utilisation in Jordan such as generic substitution, lnternational. Non-proprietary Name (INN) prescribing and Electronic Prescribing (EP). Such measures will help reduce the high expenditure on drugs in Jordan which accounts for around one-third of the national health care budget. Conclusion: A range of policy measures and changes are required to improve access to medicines in Jordan. Recommendations made included amendments to pharmaceutical policies, better enforcement of the current regulations, encouraging the use of generic medicines by introducing measures such as generic prescribing, generic substitution and public awareness education programs. These changes should result in more affordable medicines in Jordan.
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