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Annual David Sanders Lecture 2014 “Access to Medicines: the Struggle Continues”

Author: Dr Hazel Bradley

Prof Richard Laing, who gave the Annual Lecture, asserted that whilst South Africa has made significant progress in extending access to medicines in the past 20 years since democracy, 'the struggle continues‘.

Prof Richard Laing gave the Annual David Sanders Lecture at the School of Public Health, UWC on Wednesday 25 June 2014. The Annual Lecture was instituted in 2012 in celebration of Emeritus Professor David Sanders’ contribution as founding director of the School of Public Health at UWC and his influence in the field of Public Health. Prof Laing was an apposite choice as Richard and David met over 40 years ago as medical students in Zimbabwe where they were both subsequently involved in various capacities in the Zimbabwean health services. Richard spent his last three years in the country (1987-89) developing the Zimbabwean Essential Drugs Programme (ZEDAP). This set the direction for his professional career in pharmaceutical policy, notably at the World Health Organisation (WHO) from 2003-2013 and latterly back at Boston University, School of Public Health as professor of International Health. At the lecture SOPH announced that Prof Richard Laing has recently been appointed as Extraordinary Professor at the School and we look forward to ongoing collaboration in the area of pharmaceutical public health and policy.

Richard was introduced at the Annual Lecture by Bada Pharasi, Management Sciences for Health (MSH) Country Representative for South Africa, who had been a colleague in Zimbabwe during ZEDAP days. Richard drew on his vast experience to focus on critical issues influencing access to medicines. He commenced by reflecting on key moments including the first essential medicines list developed in 1977; the Nairobi conference on Rational Medicines Use which introduced a compromise by limiting the concept to the public sector; and 1998 when the compromise was broken down when 39 big PHARMA companies sued the South African government.

Over the years, many have perceived patents and patent law to be barriers to the essential medicines concept but work published by Kowalski et al (2011) quashed this assumption by showing that less than 6% of essential medicines were patent protected anywhere in the world. However, if patents are not a barrier to access to essential medicines, then pricing remains a key issue with studies showing wide variations in prices both between countries and within the public and private sectors. Ironically, even though medicines in the public or government sector may be affordable, or even free in some cases, availability is often very poor which results in patients reverting to high-priced medicines from the private sector. Affordability of medicines is a critical issue in many countries with cumulative mark-ups between manufacturers selling price and final patient price varying considerably. Studies have revealed that in some countries the cumulative mark-up can be anything up to 600 times the manufacturer‘s selling price (even up to 6000 times in El Salvador).

Generic medicines have been proposed as one answer to ensuring availability and affordability of essential medicines but, again, available data show massive variations between countries in terms of use with the United States being a world leader in generic uptake by volume (almost 80%). Austria, on the other hand, is at the other end of the scale with generic s standing at just over a third of the market share and brand loyalty remaining high even after the patent ends. The generics picture in South Africa falls between these two, with 2010 data showing generics at 71% market share and brand erosion in the year after the patent ends varying between 60-90%.

Richard cited recent work by Leng, Sanders and Pollock in South Africa that showed among some medicines, like metformin (an anti-diabetic medicine), the originator retains market share with a slight price premium, whilst in the case of fluoxetine (an anti-depressant) the originator slowly loses market share but price premium remains and for ciprofloxacin (an antibiotic), the first generic has the greatest market share but is under stiff pressure from other suppliers.

Richard concluded his lecture by pointing to several future hopes and challenges remaining for South Africa with respect to access to medicines, including the still to be unveiled National Health Insurance (NHI), which will hopefully include access to essential medicines in its package; reform of the Medicines Control Council to speed up drug registrations; and lastly reform of patent legislation resulting in faster access to generics. He asserted that whilst South Africa has made significant progress in extending access to medicines in the past 20 years since democracy, the struggle continues‘.

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