Identification of Priority Policy Research Questions …...• James Fitzgerald • Nelly Marin • Analia Porras PAHO Country level offices • Colombia – Adriana Mendoza • Dominican

Nucleus for Pharmaceutical Policies PAHO-WHO Collaborating Center for Pharmaceutical Policies

Identification of Priority Policy Research Questions on Access to Medicines in Low and Middle Income Countries in Latin America and Caribbean (LAC)

– Final Report –

A smart person learns from his own mistakes; a wise person learns from the mistakes of others.

Augusto Cury

The NAF/ENSP is the technical team in charge of activities set out in The Letter of

Agreement between Fiotec and WHO registration 2010/103768-0 Reg file E50

APW243.

Rio de Janeiro, March 2011

2

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PAHO WHO Collaboration Centre (main team)

• Vera Lucia Luiza, DSc, MSc

• Isabel Cristina Martins Emmerick, MSc

• Thiago Botelho Azeredo, Sc

• Maria Auxiliadora Oliveira, DSc, M.D., MSc

• Gladys Cecilia Restrepo Zuluaga, Pharmacist

• Paula da Silva Freitas;, Pharmacy student, trainee

Collaborators

PAHO medicines and vaccines Cluster (Head Quarter)

• James Fitzgerald

• Nelly Marin

• Analia Porras

PAHO Country level offices

• Colombia – Adriana Mendoza

• Dominican Republic – Dalia Castillo

• El Salvador - Gerardo Alfarob

• Suriname – Marisa Valdes

Acknowledgments

Prof. Maria de Fatima M. Martins – expert on bibliography serch

Paula Pimenta de Souza – support on translation into English

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Content

Research team ................................................................................................................2!Executive summary........................................................................................................6!

Background ................................................................................................................6!General objective .......................................................................................................7!Specific objectives .....................................................................................................7!Research questions .....................................................................................................7!Methods......................................................................................................................7!Ethical issues..............................................................................................................9!Results ......................................................................................................................10!

Literature review (Scientific publications and gray literature) ............................10!Interviews.............................................................................................................10!

Lessons learned ........................................................................................................13!Introduction ..................................................................................................................15!Objectives.....................................................................................................................16!

General objective .....................................................................................................16!Specific objectives ...................................................................................................16!Research questions ...................................................................................................16!

Methodology ................................................................................................................17!Literature review ......................................................................................................17!

Scientific literature on health ...............................................................................17!Documentary Review (gray literature).................................................................19!

Key informants interview.........................................................................................20!Country based interview ......................................................................................23!Expert e-mail survey ............................................................................................24!

Analysis....................................................................................................................25!Ethical issues............................................................................................................26!

Limits ...........................................................................................................................27!Results ..........................................................................................................................28!

Scientific Bibliography review ................................................................................28!Gray Literature review .............................................................................................34!Health and access to medicines research agenda in Latin America and Caribbean.34!Experts interview .....................................................................................................35!

Open-ended questions ..........................................................................................39!Closed-ended questions........................................................................................39!Prioritization criteria ............................................................................................40!Policy and research priorities ...............................................................................41!Coherence analysis...............................................................................................48!

Lessons learned ........................................................................................................54!References ....................................................................................................................54!Annex I - Framework for literature review and analysis: Scientific Literature Review on health research related to access to medicines ........................................................59!Annex II - Operating Procedure - Bibliographic Research and Revision Process.......62!Annex III – General results of the Scientific Literature Search...................................63!Annex IV. Model of Messages used to the e-mail interview.......................................65!

Invitation message....................................................................................................65!Follow up message...................................................................................................66!Acknowledgement message .....................................................................................66!

Annex V. Questionnaire used to the e-mail survey......................................................67!

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Annex VI. Questionnaire used to thee country level interviews..................................87!Annex VII. Power point presentation used to introduce the project to stakeholders ...96!Annex VIII. Papers reviwed including information by Author, Year, Title, ATM barries classification and, findings resume. .................................................................99!Annex IX. Countries background ..............................................................................113!

Colombia ................................................................................................................113!Dominican Republic...............................................................................................114!El Salvador .............................................................................................................121!Suriname ................................................................................................................124!

Annex X. Documents retrieved in the gray literature review and corresponding dimension of access to medicines addressed. Latin American Region, 2011............133!Annex XI. Interviewees .............................................................................................137!

Country level..........................................................................................................137!E-mail survey .........................................................................................................139!

Illustrations

Box 1. Items according to access to medicines WHO component. .............................20!Box 2. Matrix of coherence analysis combinations .....................................................26!Box 3. Ten leading cases of death in Suriname (2007)..............................................127! Figure 1. Percentage of paper published on the review by year of publication ...........28!Figure 2. Percentage of paper published with empiric approach by year of data colection .......................................................................................................................29!Figure 3. Scatter plots between policies being carried out by the governments and policies that the government should be carrying out, Colombia, Dominican Republic, El Salvador and Suriname. Each dot represents a policy/research priority .................50!Figure 4. Scatter plots between policies being carried out by the governments and policies that the government should be carrying out, E-mail survey and General total scores. Each dot represents a policy/research priority. ................................................51!Figure 5. Scatter plots between topics being investigated at national research centers and policies that the government should be carrying out, Colombia, Dominican Republic, El Salvador and Suriname. Each dot represents a policy/research priority .52!Figure 6. Scatter plots between topics being investigated at national research centers and policies that the government should be carrying out, E-mail survey and General total scores. Each dot represents a policy/research priority. ........................................53!Figure 7. Geographic location of all districts of Suriname. .......................................124! Table 1. Papers published by language, focus and type of article ...............................29!Table 2. Frequency of 1st author’s countries of origin. ...............................................30!Table 3. Frequency of the countries included in the studies. .......................................30!Table 4. Scientific papers classified by level of the health system according to AHPSR framework and by component of access to medicines according to WHO framework. ...................................................................................................................32!Table 5. Documents (grey literature) classified by level of health system according to AHPSR framework and by component of access to medicines according to WHO framework. ...................................................................................................................34!Table 6. Countries from the Region of Americas with Research Agenda for Health and Access to Medicines. .............................................................................................35!

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Table 7. Number of respondents per country...............................................................35!Table 8. Selected indicators for countries’ background. 2010....................................36!Table 9. Number of respondents in the E-mail survey per type of stakeholder involved in ATM.........................................................................................................................39!Table 10. Respondent ranking of criteria that should be applied to define research/policy priorities on Access to Medicines.......................................................41!Table 11. Respondent ranking of policies being carried out by the government.........44!Table 12. Respondent ranking of policies that the government should be carrying out.......................................................................................................................................45!Table 13. Respondent ranking of topics being investigated at national research centers. .........................................................................................................................46!Table 14. Respondent ranking of research topics required for the design of public health policies. .........................................................................................................................47!Table 15. Distribution of the Suriname Population, Census 2004+) .........................125!Table 16. General profile of Suriname.......................................................................125!Table 17. Health care facilities in Suriname ..............................................................126!Table 18. Population by medical plan (mode of paying for health expenditure) +) ...127!Table 19. Medicines Coverage in insurance schemes and selected public health programmes................................................................................................................131!

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! Experts on pharmaceuticals with regional experience

! Researchers with expressive scientific and technical production on access to medicines in the region in the last 5 years

! NGO and CSO activists

! People from pharmaceutical industry involved in ATM projects.

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! The project was submitted to the ENSP and to the Brazilian National Ethical Committee

! All interviews were conducted only after a written informed consent

! Names of interviewees will not be disclosed in any kind of study-related publication

! All collected information will be kept under the responsibility of NAF

! An executive summary of the final report will be shared with all interviewees

! Final results will be presented and discussed in the III ICIUM

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Box 1. Items according to access to medicines WHO component. 2 Bitrán y Asociados, 2008. Identification of Priority Research Questions in LAC within the Areas of Health Financing, Human Resources for Health and the Role of the Non-State Sector. Final Report. Bitrán y Asociados, February, 2008.

21

In relation to rational selection and use of medicines: a) Information asymmetry (user

knowledge level; communication and language barriers – as for ethnic minorities)

b) Health seeking behavior, preference for private care, preference for secondary level of care (bypass Primary health care), self medication

c) Beliefs about illness and treatment (traditional practices; demand for injections and branded medicines; prescribers and dispensers perception of quality of drugs)

d) Impact of advertisements on medicines; Incentives (or lack of, leading to private or dual practice); medicines becoming a source in financing for health services

e) Staff capacity for rational prescription and use of medicines; Training curriculum

f) Clinical treatment guidelines, and Essential Medicines List: development; incentives for implementation; operational mechanisms; standardization (including between private and public sectors)

g) Incentives for rational use of medicines; for implementation of generic policy

h) Staff deployment i) Pharmacovigilance, information on

adverse drug reaction and other problems related to medicines

j) Medicines information system (not only price information) / competing with medicines advertisement

k) Intersectoral initiatives (e.g. rational use of medicines in schools - role of Ministry of Education)

In relation to pricing / affordability: a) High out of pocket payment (OOP) b) Opportunity costs

c) Community participation in medicine delivery arrangements

d) Medicines prices variation: according to geographical location (e.g. urban / rural differences, higher prices in remote areas); price differential between public and private

e) Medicines price information system f) Impact of prices on access g) Policy and regulation for medicines

price h) Incentives for implementation of

generic policy i) Patents and intellectual property issues j) Finance policies: taxes, autonomy,

privatization; Exemption systems k) Trade and economic goals (impact of

health sector policies outside the health sector)

l) Budget allocation to health m) Medicines Production

In relation to sustainable financing: a) Community financing arrangements b) Role of government subsidies at

community level c) Focal models of subside d) Health provider payment methods e) Health insurance coverage and models f) Government budgets for medicines g) Reimbursement policies h) Cost containment policies i) Donor funding - Harmonization and

Alignment - verticalized donor support j) Patents and intellectual property issues k) Finance policies: taxes, autonomy,

privatization l) Trade and economic goals (impact of

health sector policies outside the health sector)

m) Budget allocation to health

22

In relation to reliable health system / health system structure: a) Geographical accessibility: physical

barriers; distance to facilities; remoteness (combination of physical barriers and infrastructure weakness)

b) Distribution systems and supply chains

c) Pharmaceutical services at local level d) Informal markets - substandard quality

and counterfeit medicines e) Traditional medicine (e.g. unclear

distinction between allopathy and non-allopathy)

f) Staff and technical capacity: for supply management; with managerial, interpersonal and information technology (IT) skills, with local language skills

g) Responsiveness to patients needs; differential responsiveness between public and private

h) Public-private mix: reliance on private sector delivery; public-private partnerships and their role in access to medicines

i) Central procurement policies vs. decentralization

j) Availability of medicines (specially in public sector)

k) Quality assurance l) Coordination between health policies

and medicines policies; referral policy / referral system

m) Monitoring and evaluation systems; funding for M&E

n) Governance and governing: Law and regulation enforcement; Transparency and accountability

o) Regional integration and economic cooperation (example: UNASUL, MERCOSUL)

p) Promotion of Research and Development - new drugs / neglected diseases.

q) Medicines Production

23

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26

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Box 2. Matrix of coherence analysis combinations Policies that the government

should be carrying out Topics being investigated at

national research centers Topics required for the design

of public health policies

Policies being carried out by the government

Does the government respond to the needs of the population?

Is scientific evidence being generated to assess, change or improve current policies?

Should scientific evidence aimed at assessing, changing or improving current policies be generated?

Policies that the government should be carrying out

-

Is scientific evidence being generated to support policies that respond to the needs of the population?

Do respondents value scientific evidence to support policies that respond to the needs of the population?

Topics being investigated at national research centers

- Is research moving in the right direction?

Source: Adapted from Bristán y Asociados, 2008.

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29

Figure 2. Percentage of paper published with empiric approach by year of data colection

Table 1. Papers published by language, focus and type of article

Category Frequency (N)

Percent (%)

English 41 53.2 Portuguese 29 37.7 Spanish 7 9.1

Language

Total 77 100.0 General 56 72.7 Specific 21 27.3

Focus

Total 77 100.0 Empiric 66 85.7 Review 11 14.3

Type of article

Total 77 100.0 !

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30

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Table 2. Frequency of 1st author’s countries of origin.

Country Frequency (N) Percent (%) Brazil 44 57.1 USA 16 20.8 Not LAC country 9 11.7 Other LAC countries 7 9.1 !

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Table 3. Frequency of the countries included in the studies.

Country Frequency (N) Percent (%) Brazil 53 68.8 Mexico 12 15.6 Colombia 9 11.7 Argentina 8 10.4 Peru 8 10.4 Bolivia 6 7.8 Costa Rica 6 7.8 Honduras 6 7.8 Ecuador 5 6.5 El Salvador 5 6.5 Nicaragua 5 6.5 Guatemala 4 5.2 Venezuela 4 5.2 Dominican Republic 3 3.9 Panama 3 3.9 Uruguay 3 3.9 Guyana 2 2.6 Paraguay 2 2.6 USA 2 2.6 Barbados 1 1.3 Belize 1 1.3 Caribbean 1 1.3 Chile 1 1.3 India 1 1.3 Jamaica 1 1.3 Nigeria 1 1.3 Saint Kitts and Nevis 1 1.3 St. Vincent 1 1.3 Suriname 1 1.3 Trinidad and Tobago 1 1.3 !

31

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32

Table 4. Scientific papers classified by level of the health system according to AHPSR framework and by component of access to medicines according to WHO framework.

Health system Level (AHPSR framework) Frequency (N) Percent (%) Individual, household and community level 28 36.4 Public and private health service delivery channels

30 39.0

Health Sector 44 57.1 Beyond the health sector 16 20.8 Component (Who framework) Rational selection and use 40 51.9 Affordability 29 37.7 Sustainable financing 15 19.5 Reliable health system 54 70.1 Total of papers reviewed 77 100.0 !

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34

9$!80.'%')5! '(!0(!$?+$,'$(4$! '(!J$,3:!">*!-)3%'$-! )0.6$%!09*3)! &,01'.')'$-!*&! )#$!

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Table 5. Documents (grey literature) classified by level of health system according to AHPSR framework and by component of access to medicines according to WHO framework.

Health System Level (AHPSR framework) Frequency (N) Percent (%) Individual, household and community level 4 12.1 Public and private health service delivery channels 4 12.1

Health Sector 26 78.8 Beyond the health sector 19 57.6 Component (Who framework) Rational selection and use 7 21.2 Affordability 13 39.4 Sustainable financing 15 45.5 Reliable health system 24 72.7 Total of papers reviewed 33 100.0

G-".19+")*+"##-77+1'+H-*2#2)-7+&-7-"&#9+"%-)*"+2)+="12)+FH-&2#"+")*+L"&2//-")+

B$0.)#! ,$-$0,4#! 01$(%0-! >$,$! '%$()'&'$%! '(! &'8$! 4*3(),'$-:! P*3,! *&! )#$/!>$,$!

3++$,G/'%%.$! 0(%! *($! >0-! .*>$,! /'%%.$G'(4*/$! 4*3(),'$-:! P,*/! )#$-$7! *(.5!

)>*7!Z,0<'.!0(%!J0,013057!'(4.3%$%!K"@G,$.0)$%!'--3$-!M"09.$!iN:!!

35

Table 6. Countries from the Region of Americas with Research Agenda for Health and Access to Medicines.

Country Income level1 Source2

Access to medicines

in the health

research agenda

Year of more

uppdated version found

Argentina Upper middle http://www.healthresearchweb.org/files/RE_NEURO_final.pdf

- 2007

Brazil Upper middle http://www.healthresearchweb.org/files/National%20Agenda%20of%20Priorities%20in%20Health%20Research.pdf

Yes 2006

Costa Rica Upper middle http://www.healthresearchweb.org/files/Agenda%20Nacional%20de%20Investigaci%C3%B3n%20y%20Desarrollo%20Tecnol%C3%B3gico%20en%20Salud%202005-2010.pdf

- 2005

Paraguay Lower middle http://www.healthresearchweb.org/files/Agenda%20Nac.%20Prioridades%20Inv.2008%

202013.pdf

Yes 2008

Peru Upper middle http://www.healthresearchweb.org/files/Prioridades_de_Investigacion_en_Salud.pdf

- 2007

1. http://datos.bancomundial.org/pais 2. http://www.healthresearchweb.org/common/index.php

<M5-&17+2)1-&32->+

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*&! )#$!-$.$4)$%!-)06$#*.%$,-!>$,$!3(080'.09.$!%3,'(1!)#$!+$,'*%!4*(-'%$,$%! &*,!

%0)0! 4*..$4)'*(! '(! $04#! *&! )#$! )>*! 4*3(),'$-:! R(! U*.*/9'07! 0! #'1#$,! (3/9$,! *&!

-)06$#*.%$,-! >$,$! '(4.3%$%7! %3$! )*! 0(! '(4,$0-$%! '()$,$-)! 0(%! +0,)'4'+0)'*(! *&!

YOC!,$+,$-$()0)'8$-:!eQ! '()$,8'$>-!>$,$!4*/+.$)$%! '(!4*3(),5!8'-')-:!"#$!)*)0.!

(3/9$,!*&!,$-+*(%$()-!+$,!4*3(),5!40(!9$!&*3(%!0)!"09.$!j:!

Table 7. Number of respondents per country.

Information Source Number of Respondents

Country Visits 49 Colombia 15

Dominican Republic 12 El Salvador 11

Suriname 11

36

Information Source Number of Respondents

E-mail survey 35 Argentine 3

Bolivia 1 Brazil 13

Colombia 3 Costa Rica 1

Ecuador 6 USA 4

Guatemala 1 Mexico 1

Peru 2 Total 84

Source: Authors.

U0,04)$,'<0)'*(! *&! )#$! 4*3(),'$-! '-! +,$-$()$%! *(! K(($?! Rp! M+:! HHIN! q0(%! 0,$!

-3//0,'<$%!*(!"09.$!F:!

Table 8. Selected indicators for countries’ background. 2010. Selected indicators COL DOR ELS SUR

Demografic1 Population [Thousands] 46.300 10.225 6.194 524 Proportion of urban population [%] 75.1 69.2 64.3 69.4 Proportion of population less than 15 years old [%]

28.5 30.7 31.0 28.3

Proportion of population 60 years and older [%]

9.6 9.9 11.7 10.3

Dependency ratio [Dependent population per 100 productive population]

52.4 59.3 63.5 53.9

Crude birth rate [per 1,000 pop.] 19.8 21.8 20.1 18.5 Life expectancy at birth [Years] 73.4 72.8 72 69.4 SocioEconomics1 Literacy rate [%] 93.4 88.2 84.0 90.7 Gross National Income (GNI), per capita, current US$ (Atlas Method) [$ per capita]

4.62 4.33 3.46 4.76

Gross National Income (GNI), per capita, international $ (PPP-adjusted) [US$]

8.43 7.8 6.63 6.68

Gross Domestic Product (GDP), per capita, international $ (PPP-adjusted) [US$]

8,797.31

8,125.29

6,799.40

7,400.66

Annual GDP growth rate [%] 2.5 5.3 2.5 5.1 Highest 20%/Lowest 20% income ratio [Ratio] 26.6 12.3 12.2 18.6 Proportion of population below the international poverty line [%]

16.0 4.4 6.4 15.5

Proportion of population below the national poverty line [%]

34.0 16.8 16.5 ...

Unemployed proportion of the labor force [%] 11.7 15.6 6.6 13.8 Inflation: consumer prices index's annual growth rate [%]

7.0 10.6 6.7 13.2

Health condition1 Infant mortality rate [per 1,000 lb] (Reported less than 1 year)

15.3 28.8 21.5 19.8

37

Selected indicators COL DOR ELS SUR Infant mortality rate [per 1,000 lb] (Estimated less than 1 year)

17.5 26.9 19.1 26.2

Under-5 mortality, estimated [per 1,000 lb] 24.4 30.4 24.6 29.7 Maternal mortality ratio, reported [per 100,000 lb]

75.6 133.5 64.5 184.3

Annual proportion of registered deaths under 5 years of age due to intestinal infectious diseases (ADD) [%]

3.9 4.7 5.2 1.4

Annual proportion of registered deaths under 5 years of age due to acute respiratory infections (ARI) [%]

7.9 4.7 12.4 4.9

General estimated mortality rate, adjusted by age [per 1,000 pop.]

6.6 7.3 6.1 6.9

Estimated general mortality rate [per 1,000 pop.]

5.5 6.2 5.8 6.2

Estimated mortality rate from communicable diseases, adjusted by age [per 100,000 pop.]

51.5 79.6 68.4 83.6

Estimated mortality rate from communicable diseases [per 100,000 pop.]

44.4 72.3 64.7 80.9

Estimated mortality rate due to tuberculosis [per 100,000 pop.]

2.4 4.4 1 1.7

Number of registered deaths due to Aids [Deaths]

2.469 1,026 688 185

Estimated mortality rate from diseases of the circulatory system, age adjusted [per 100,000 pop.]

198.6 242.9 127.2 269.3

Estimated mortality rate from diseases of the circulatory system [per 100,000 pop.]

156.5 190.4 122.1 233.4

Estimated mortality rate from external causes, adjusted by age [per 100,000 pop.]

103.2 85.7 124.6 77.1

Estimated mortality rate from external causes [per 100,000 pop.]

105.2 83.2 123.9 76.5

Estimated mortality rate from diabetes mellitus [per 100,000 pop.]

19.4 28.7 32.3 29.2

Health Service Proportion of deliveries attended by trained personnel [%]

98.0 97.8 84.9 90.0

Physicians ratio [10,000 hab.] 15.0 13.2 20.1 8.9 Professional nurses ratio [10,000 hab.] 8.0 2.0 5.1 16.3 Dentists ratio [10,000 hab.] 9.0 1.4 8.1 1.0 Number of outpatient care facilities [Facilities] 21384.

0 5.7 927.0 348.0

Hospital beds ratio [per 1,000 pop.] 1.0 1.0 1.1 3.1 Outpatient health care visits ratio [per 1,000 pop.]

... 1350.7 2084.3 1189.9

Hospital discharges ratio [per 1,000 pop.] 123.5 46.9 54.0 96.5 Annual national health expenditure as a proportion of the GDP [%] (Public)

3.5 1.8 2.9 3.8

Annual national health expenditure as a proportion of the GDP [%] (Private)

1.5 5.3 5.0 1.0

Pharmaceutical Sector National Medicines Policy (NMP) Document yes yes yes yes NMP Official or Draft Official Official Draft Official

38

Selected indicators COL DOR ELS SUR NMP implementation plan yes yes yes NMP integrated into NHP yes yes yes yes National assessment/indicator study (NAS) yes yes No yes NAS covering - Rational use/prescription audit (RUA)

yes yes No No

NAS covering - Access yes yes No yes Medicines production capability - R&D No No .... No Medicines production capability - Production of pharmaceutical starting materials

No No .... No

Medicines production capability - Formulation from pharmaceutical starting material

Yes Yes Yes Yes

Medicines production capability - Repackaging finished dosage forms

yes yes yes yes

Patents granted by national office yes yes yes No National legislation modified to implement TRIPS Agreement

yes yes No

World Bank 3 List of economies (July 2007) Upper

Middle Upper Middle

Lower Middle

Upper Middle

Source: 1. http://www.paho.org/English/SHA/coredata/tabulator/newsqlTabulador.asp, accessed in 29 mar 2011 2. WHO Pharmaceutical Situation Assessment level I Questionnaire, 2007 3. http://data.worldbank.org/country, accessed in 29 mar 2011 Countries : COL= Colombia ; DOR= Dominican Republic ; ELS= El Salvador ; SUR= Suriname

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39

Table 9. Number of respondents in the E-mail survey per type of stakeholder involved in ATM.

Invitation E-mails sent Respondents Stakeholder involved in ATM n % n %

Response rate

Decision maker (MoH representative) 6 6,1% 4 11,4% 66.7%

International Agency representative (PAHO focal point on medicines)

26 26,5% 5 14,3% 19.2%

NGO representative 26 26,5% 8 22,9% 30.8% Researcher 32 32,7% 17 48,6% 53.1% Pharmaceutical industry representative 8 8,2% 1 2,9% 12.5%

Total 98 100,0% 35 100,0% 35.7% Source: Authors.

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3 Bitrán y Asociados, 2008. Identification of Priority Research Questions in LAC within the Areas of Health Financing, Human Resources for Health and the Role of the Non-State Sector. Final Report. Bitrán y Asociados, February, 2008

41

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Table 10. Respondent ranking of criteria that should be applied to define research/policy priorities on Access to Medicines.

Items (proposed criteria) Colombia Dominican Republic

El Salvador Suriname E-mail

Survey Total

g Relevance (Magnitude of the problem; Persistence of the problem; Impact on health; Urgency)

1,5 1,8 0,6 0,9 2,0 6,7

b Feasibility (Capacity of the system to carry out the research; Funding support; Justification of the cost/investment; Justification of time)

0,8 1,0 0,8 0,7 0,7 4,1

i Research utilization (Adequacy and usefulness of the current knowledge base (avoiding duplication); Applicability of the research outcome; Availability of cost-effective interventions (access); Operational effectiveness)

1,0 0,3 0,5 1,1 1,0 3,9

f Political will/ acceptability/ commitment 0,5 1,1 0,9 0,8 0,5 3,8 c Human rights issues; Equity focus; Ethical and moral

issues 0,7 1,3 0,9 0,3 0,6 3,7

h Responsiveness to the National Health Policy or national goals

0,7 0,8 0,4 0,8 1,0 3,6

a Community concern/demand; Environmental health and sociopolitical effects

0,3 0,3 1,1 0,9 0,4 3,0

d Impact on development; Economic impact 0,2 0,6 0,5 0,4 0,3 1,9 e Partnership building; Research capacity building 0,3 0,2 0,0 0,1 0,4 1,0

Source: Authors.

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43

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44

Table 11. Respondent ranking of policies being carried out by the government.

Dimensions Items (policy or research topics) Colombia Dominican

Republic El

Salvador Suriname E-mail Survey Total

Rational Selection and Use of Medicines

f Clinical treatment guidelines, and Essential Medicines List (EML): development; incentives for implementation; operational mechanisms; standardization (including between private and public sectors)

4,1 3,3 3,4 3,5 3,5 17,7

i Pharmacovigilance, Information on adverse drug reaction and other problems related to medicines 3,0 1,3 1,5 2,2 2,1 10,1

e Staff capacity for rational prescription and use of medicines; Training curriculum 0,6 1,8 2,0 1,1 1,6 7,1 g Incentives for rational use of medicines; for implementation of generic policy 1,2 0,5 0,8 1,0 2,3 5,9

b Health seeking behavior, preference for private care, preference for secondary level of care (bypassing primary health care), self medication 0,7 2,0 0,1 1,4 1,6 5,8

j Medicines information system (not only price information) / competing with medicines advertisement 0,8 1,1 1,5 0,6 0,7 4,7

d Impact of advertisements on medicines; Incentives (or lack of, leading to private or dual practice); medicines becoming a source in financing for health services 0,8 0,3 1,5 0,0 0,7 3,3

k Intersectorial initiatives (e.g. rational use of medicines in schools - role of Ministry of Education) 0,4 0,0 0,9 0,5 0,4 2,2

c Beliefs about illness and treatment (traditional practices; demand for injections and branded medicines; prescribers and dispensers perception of quality of drugs) 0,0 0,7 0,2 0,4 0,7 1,9

h Staff deployment 0,0 0,3 0,0 1,1 0,5 1,8

a Information asymmetry (user knowledge level; communication and language barriers – as for ethnic minorities) 0,2 0,2 0,1 0,6 0,4 1,5

Total 11,9 11,4 11,9 12,4 14,4 62,0 Pricing / Affordability g Policy and regulation for medicines price 2,9 0,5 3,0 2,6 2,4 11,4 l Budget allocation to health 1,2 1,9 1,7 2,5 2,1 9,4 f Impact of prices on access 1,3 1,4 3,4 1,1 1,0 8,2 a High out of pocket payment (OOP) 0,6 3,0 1,8 0,8 1,4 7,6 i Patents and intellectual property issues 2,7 0,8 0,5 0,8 1,6 6,4 h Incentives for implementation of generic policy 0,7 0,9 0,8 1,1 1,5 4,9 e Medicines price information system 2,1 0,8 0,2 0,1 1,7 4,8 j Finance policies: taxes, autonomy, privatization; Exemption systems 1,1 0,5 0,5 1,6 0,6 4,4

d Medicines prices variation: according to geographical location (e.g. urban / rural differences, higher prices in remote areas); price differential between public and private 0,0 1,3 0,4 1,5 0,4 3,6

m Medicines Production 0,4 0,3 0,0 0,5 1,6 2,9 k Trade and economic goals (impact of health sector policies outside the health sector) 0,2 0,3 0,0 0,6 0,5 1,6 b Opportunity costs 0,0 0,0 0,0 0,6 0,1 0,8 c Community participation in medicine delivery arrangements 0,0 0,3 0,0 0,0 0,2 0,6 Total 13,2 12,0 12,4 14,0 14,9 66,5 Reliable Health System / Health System Structure

a Geographical accessibility: physical barriers; distance to facilities; remoteness (combination of physical barriers and infrastructure weakness) 0,7 2,2 3,6 2,6 1,1 10,2

j Availability of medicines (specially in public sector) 0,9 1,7 1,8 2,1 2,4 8,8 b Distribution systems and supply chains 1,1 2,6 1,3 1,8 1,7 8,5 i Central procurement policies vs. decentralization 2,1 2,7 0,5 1,0 1,8 8,1 k Quality assurance 1,9 1,6 1,1 1,1 1,1 6,8

f Staff and technical capacity: for supply management; with managerial, interpersonal and information technology (IT) skills, with local language skills (English) 1,3 0,7 1,3 0,8 1,1 5,1

c Pharmaceutical services at local level 0,5 1,3 0,1 1,7 1,1 4,7 l Coordination between health policies and medicines policies; referral policy / referral system 0,3 0,6 0,9 0,5 0,8 3,0 d Informal markets - substandard quality and counterfeit medicines 1,0 0,9 0,0 0,1 0,5 2,5 n Governance and governing: Law and regulation enforcement; Transparency and accountability 0,7 0,3 0,4 0,2 0,7 2,2

h Public-private mix: reliance on private sector delivery; public-private partnerships and their role in access to medicines 0,4 0,1 0,0 0,7 0,8 2,0

o Regional integration and economic cooperation (example: UNASUL, MERCOSUL) 0,5 0,3 0,2 0,1 0,7 1,8 g Responsiveness to patients needs; differential responsiveness between public and private 0,3 0,2 0,7 0,0 0,6 1,8 q Medicines Production 0,5 0,0 0,0 0,1 0,5 1,1 m Monitoring and evaluation systems; funding for M&E 0,4 0,2 0,1 0,0 0,3 0,9 p Promotion of Research and Development - new drugs / neglected diseases. 0,1 0,0 0,3 0,0 0,4 0,8 e Traditional medicine (e.g. unclear distinction between allopathy and non-allopathy) 0,3 0,0 0,0 0,0 0,2 0,5 Total 13,1 15,0 12,2 12,8 15,7 68,7 Sustainable Financing f Government budgets for medicines 0,4 1,9 3,1 2,8 2,6 10,8 m Budget allocation to health 1,1 1,9 3,5 1,9 2,3 10,7 e Health insurance coverage and models 1,2 2,9 0,4 3,3 1,7 9,4 h Cost containment policies 1,9 0,9 1,6 1,2 1,2 6,9 d Health provider payment methods 1,9 1,2 0,1 1,4 0,7 5,2 c Focal models of subside 1,8 1,8 0,5 0,0 0,9 4,9 i Donor funding – Harmonization and Alignment – verticalized donor support 0,0 0,8 1,7 1,1 0,5 4,0 j Patents and intellectual property issues 1,5 0,4 0,2 0,6 1,2 3,9 b Role of government subsidies at community level 0,7 1,3 0,3 1,0 0,7 3,9 k Finance policies: taxes, autonomy, privatization 0,9 0,5 0,6 0,8 0,8 3,7 g Reimbursement policies 1,0 0,3 0,2 0,5 0,8 2,7 l Trade and economic goals (impact of health sector policies outside the health sector) 0,5 0,4 0,1 0,4 0,5 1,8 a Community financing arrangements 0,0 0,0 0,0 0,0 0,5 0,5 Total 12,9 14,3 12,2 14,9 14,2 68,5

45

Table 12. Respondent ranking of policies that the government should be carrying out.


Republic El




0,9 2,4 2,6 3,6 2,7 12,4

e Staff capacity for rational prescription and use of medicines; Training curriculum 2,1 2,1 2,9 1,5 2,9 11,5


g Incentives for rational use of medicines; for implementation of generic policy 1,0 2,0 1,5 1,4 1,8 7,6







h Staff deployment 0,0 0,0 0,0 0,4 0,9 1,2 Total 13,2 14,6 12,8 14,6 16,6 71,8 Pricing / Affordability g Policy and regulation for medicines price 1,5 2,8 2,2 2,3 2,3 10,9 a High out of pocket payment (OOP) 2,0 2,8 1,3 1,3 1,8 9,1 f Impact of prices on access 1,8 1,3 1,1 1,7 2,0 8,0 e Medicines price information system 1,2 1,6 1,4 1,0 1,3 6,4 h Incentives for implementation of generic policy 1,4 1,6 1,7 0,3 1,4 6,4 l Budget allocation to health 0,1 0,3 1,9 2,1 1,7 6,0 j Finance policies: taxes, autonomy, privatization; Exemption systems 0,2 0,8 2,0 1,8 1,1 5,8


m Medicines Production 0,8 0,4 0,7 0,6 1,5 4,1 i Patents and intellectual property issues 0,3 0,3 1,5 0,6 1,3 3,9 b Opportunity costs 1,2 0,3 0,1 0,6 0,6 2,9 k Trade and economic goals (impact of health sector policies outside the health sector) 0,5 0,8 0,3 0,5 0,4 2,3 c Community participation in medicine delivery arrangements 0,5 0,8 0,0 0,0 0,5 1,9 Total 13,9 14,6 14,1 14,2 16,6 73,3 Reliable Health System / Health System Structure


b Distribution systems and supply chains 0,9 1,9 2,3 1,5 1,3 7,9


k Quality assurance 0,5 1,8 0,6 2,4 1,5 6,8 j Availability of medicines (specially in public sector) 0,7 1,3 0,7 1,9 1,7 6,3 g Responsiveness to patients needs; differential responsiveness between public and private 1,5 0,7 1,7 0,8 1,0 5,7 p Promotion of Research and Development - new drugs / neglected diseases. 1,8 0,7 1,4 0,6 1,2 5,7

n Governance and governing: Law and regulation enforcement; Transparency and accountability 0,3 1,8 0,4 1,5 1,2 5,1

l Coordination between health policies and medicines policies; referral policy / referral system 0,9 0,8 0,6 0,4 1,8 4,5 c Pharmaceutical services at local level 0,7 0,8 1,2 0,7 1,0 4,3 i Central procurement policies vs. decentralization 0,1 1,4 0,0 0,6 0,9 3,0 m Monitoring and evaluation systems; funding for M&E 0,1 0,3 0,8 0,7 0,9 2,8 d Informal markets - substandard quality and counterfeit medicines 0,6 0,1 0,0 1,0 0,2 1,9 o Regional integration and economic cooperation (example: UNASUL, MERCOSUL) 1,0 0,2 0,1 0,4 0,2 1,8 e Traditional medicine (e.g. unclear distinction between allopathy and non-allopathy) 0,5 0,0 0,5 0,5 0,3 1,8 q Medicines Production 0,5 0,3 0,4 0,1 0,5 1,8


Total 14,9 15,0 14,5 15,0 16,9 76,3 Sustainable Financing f Government budgets for medicines 1,7 2,7 2,5 1,6 2,5 11,0 m Budget allocation to health 1,7 2,0 3,1 1,7 2,2 10,7 e Health insurance coverage and models 1,2 2,8 1,4 3,3 2,1 10,7 h Cost containment policies 1,8 2,2 2,1 1,5 1,5 9,1 k Finance policies: taxes, autonomy, privatization 0,7 1,0 0,7 0,7 1,1 4,2 b Role of government subsidies at community level 1,1 0,6 0,1 1,8 0,4 4,0 j Patents and intellectual property issues 0,7 0,2 1,2 0,1 1,8 3,9 d Health provider payment methods 0,6 1,1 0,4 1,3 0,5 3,8 g Reimbursement policies 1,1 0,3 0,6 0,7 0,9 3,7 c Focal models of subside 0,7 1,3 0,3 0,5 0,8 3,5 l Trade and economic goals (impact of health sector policies outside the health sector) 1,0 0,5 0,5 0,2 0,7 2,9 a Community financing arrangements 0,9 0,3 0,1 0,6 0,5 2,4 i Donor funding – Harmonization and Alignment – verticalized donor support 0,2 0,6 0,4 0,4 0,4 1,9 Total 13,3 15,4 13,3 14,5 15,4 71,8

46

Table 13. Respondent ranking of topics being investigated at national research centers.


Republic El




3,0 1,7 0,8 2,2 2,1 9,8




g Incentives for rational use of medicines; for implementation of generic policy 1,1 0,8 0,5 0,4 0,9 3,6 e Staff capacity for rational prescription and use of medicines; Training curriculum 0,0 0,7 0,3 0,7 1,3 3,0




h Staff deployment 0,3 0,3 0,0 0,5 0,4 1,5


Total 8,8 6,3 7,6 8,7 10,9 42,4 Pricing / Affordability f Impact of prices on access 1,5 1,5 3,0 0,4 1,9 8,3 i Patents and intellectual property issues 1,5 1,3 1,8 0,5 2,0 7,1 g Policy and regulation for medicines price 1,2 0,7 1,8 0,9 1,1 5,7 a High out of pocket payment (OOP) 0,1 3,1 0,8 0,0 1,3 5,3 e Medicines price information system 2,0 0,8 0,5 0,4 1,2 4,8 l Budget allocation to health 0,6 2,0 0,5 0,5 1,1 4,6


m Medicines Production 0,7 0,2 0,0 0,8 1,1 2,8 h Incentives for implementation of generic policy 0,8 0,0 0,4 0,7 0,6 2,5 j Finance policies: taxes, autonomy, privatization; Exemption systems 0,1 0,4 0,7 0,5 0,4 2,2 k Trade and economic goals (impact of health sector policies outside the health sector) 0,7 0,5 0,1 0,0 0,5 1,7 c Community participation in medicine delivery arrangements 0,2 0,0 0,3 0,0 0,2 0,6 b Opportunity costs 0,2 0,0 0,0 0,0 0,2 0,4 Total 9,8 11,6 11,0 5,1 12,8 50,3 Reliable Health System / Health System Structure j Availability of medicines (specially in public sector) 0,9 1,7 2,5 0,6 2,7 8,3 k Quality assurance 0,6 0,8 0,6 1,4 0,7 4,0 c Pharmaceutical services at local level 0,1 1,6 0,6 0,4 1,3 4,0 b Distribution systems and supply chains 0,3 1,3 1,5 0,0 0,8 3,9


d Informal markets - substandard quality and counterfeit medicines 1,8 0,7 0,1 0,4 0,2 3,1 e Traditional medicine (e.g. unclear distinction between allopathy and non-allopathy) 1,3 0,0 0,0 1,2 0,5 3,0 n Governance and governing: Law and regulation enforcement; Transparency and accountability 0,9 0,3 0,6 0,5 0,5 2,8 l Coordination between health policies and medicines policies; referral policy / referral system 0,7 0,1 0,8 0,5 0,7 2,7 p Promotion of Research and Development - new drugs / neglected diseases. 1,2 0,0 0,3 0,5 0,6 2,6 g Responsiveness to patients needs; differential responsiveness between public and private 0,9 0,4 0,4 0,2 0,7 2,5 i Central procurement policies vs. decentralization 0,7 0,6 0,0 0,5 0,5 2,3 m Monitoring and evaluation systems; funding for M&E 0,4 0,2 0,0 0,8 0,6 2,0


q Medicines Production 0,9 0,0 0,0 0,0 0,7 1,7 o Regional integration and economic cooperation (example: UNASUL, MERCOSUL) 0,0 0,4 0,4 0,3 0,5 1,6


Total 11,2 10,1 9,5 7,9 12,6 51,2 Sustainable Financing e Health insurance coverage and models 1,0 2,2 0,4 2,2 1,7 7,4 m Budget allocation to health 0,9 1,4 3,0 0,5 1,5 7,2 f Government budgets for medicines 1,1 0,9 1,5 0,5 1,4 5,4 h Cost containment policies 2,2 0,9 1,1 0,2 0,7 5,1 k Finance policies: taxes, autonomy, privatization 1,3 0,6 0,8 1,2 1,2 5,1 j Patents and intellectual property issues 1,1 0,8 0,9 0,4 1,9 5,0 c Focal models of subside 0,5 2,4 0,6 0,0 0,6 4,2 g Reimbursement policies 2,5 0,1 0,3 0,0 0,4 3,2 i Donor funding – Harmonization and Alignment – verticalized donor support 0,0 0,7 0,0 0,7 0,6 2,0 d Health provider payment methods 0,5 0,8 0,0 0,0 0,5 1,7 l Trade and economic goals (impact of health sector policies outside the health sector) 0,1 0,3 0,3 0,0 0,5 1,1 b Role of government subsidies at community level 0,1 0,2 0,0 0,0 0,5 0,8 a Community financing arrangements 0,0 0,0 0,5 0,0 0,3 0,7 Total 11,2 11,1 9,3 5,6 11,6 48,8

47

Table 14. Respondent ranking of research topics required for the design of public health policies.


Republic El




0,8 2,8 0,8 2,5 2,9 9,8

e Staff capacity for rational prescription and use of medicines; Training curriculum 1,9 2,6 1,6 0,7 2,4 9,3




g Incentives for rational use of medicines; for implementation of generic policy 1,7 1,1 0,6 1,2 1,6 6,2




k Intersectorial initiatives (e.g. rational use of medicines in schools - role of Ministry of Education) 0,5 0,5 0,5 0,5 0,7 2,6 h Staff deployment 0,2 0,0 0,5 0,0 0,6 1,3 Total 12,1 14,7 10,9 14,0 15,8 67,4 Pricing / Affordability f Impact of prices on access 1,5 2,3 3,5 1,5 2,1 11,0 g Policy and regulation for medicines price 0,8 2,2 1,9 2,4 2,1 9,4 a High out of pocket payment (OOP) 2,6 2,8 1,1 0,5 1,7 8,8 e Medicines price information system 1,3 2,2 0,2 1,1 0,9 5,7 i Patents and intellectual property issues 0,5 0,4 2,3 0,9 1,5 5,6


m Medicines Production 1,0 0,5 1,5 0,9 1,3 5,1 h Incentives for implementation of generic policy 1,3 1,8 0,4 0,3 1,3 5,0 j Finance policies: taxes, autonomy, privatization; Exemption systems 0,5 1,1 0,5 1,5 0,9 4,7 l Budget allocation to health 0,6 0,3 0,2 1,6 1,6 4,3 b Opportunity costs 1,7 0,0 0,0 1,5 0,6 3,7 k Trade and economic goals (impact of health sector policies outside the health sector) 0,3 0,4 0,1 0,5 0,4 1,7 c Community participation in medicine delivery arrangements 0,3 0,4 0,1 0,1 0,5 1,3 Total 14,1 15,0 12,8 14,0 15,7 71,6 Reliable Health System / Health System Structure k Quality assurance 0,9 2,1 2,5 2,2 0,9 8,6 j Availability of medicines (specially in public sector) 0,4 1,5 1,6 2,0 1,6 7,2


l Coordination between health policies and medicines policies; referral policy / referral system 1,1 1,2 1,1 0,3 1,9 5,5 d Informal markets - substandard quality and counterfeit medicines 1,5 0,9 1,5 1,1 0,4 5,4


b Distribution systems and supply chains 0,6 1,7 0,3 1,5 1,2 5,3 p Promotion of Research and Development - new drugs / neglected diseases. 1,3 0,5 1,6 0,5 0,9 4,9 g Responsiveness to patients needs; differential responsiveness between public and private 0,8 0,6 0,5 1,1 1,5 4,5 n Governance and governing: Law and regulation enforcement; Transparency and accountability 0,3 1,0 0,6 0,5 0,9 3,4 m Monitoring and evaluation systems; funding for M&E 0,4 0,8 0,4 0,6 1,1 3,3 i Central procurement policies vs. decentralization 0,0 1,3 0,4 0,8 0,6 3,0 e Traditional medicine (e.g. unclear distinction between allopathy and non-allopathy) 0,8 0,3 0,4 0,9 0,3 2,6 q Medicines Production 0,9 0,3 0,4 0,1 0,8 2,5 c Pharmaceutical services at local level 0,7 0,0 0,4 0,6 0,7 2,4


o Regional integration and economic cooperation (example: UNASUL, MERCOSUL) 0,3 0,0 0,8 0,0 0,3 1,3 Total 13,6 14,8 14,4 14,5 16,4 73,5 Sustainable Financing h Cost containment policies 1,8 3,2 1,4 2,1 2,0 10,4 e Health insurance coverage and models 0,9 2,1 0,9 2,8 2,1 8,9 m Budget allocation to health 1,1 1,1 3,2 1,5 1,7 8,7 f Government budgets for medicines 1,3 1,7 1,5 1,1 2,3 7,8 k Finance policies: taxes, autonomy, privatization 1,5 1,5 0,8 2,0 1,2 7,0 j Patents and intellectual property issues 1,2 0,4 2,0 0,1 1,9 5,7 g Reimbursement policies 1,0 0,7 1,5 0,8 0,9 4,9 b Role of government subsidies at community level 1,7 0,5 0,5 1,4 0,3 4,4 l Trade and economic goals (impact of health sector policies outside the health sector) 0,5 1,8 0,9 0,3 0,9 4,3 d Health provider payment methods 0,5 1,0 0,7 0,7 0,6 3,6 a Community financing arrangements 0,7 0,5 0,1 1,2 0,5 2,9 c Focal models of subside 0,2 0,3 0,8 0,0 0,7 2,0 i Donor funding – Harmonization and Alignment – verticalized donor support 0,3 0,3 0,5 0,3 0,3 1,7 Total 12,7 15,0 14,6 14,3 15,6 72,2

48

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49

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50

Figure 3. Scatter plots between policies being carried out by the governments and policies that the government should be carrying out, Colombia, Dominican Republic, El Salvador and Suriname. Each dot represents a policy/research priority

51

Figure 4. Scatter plots between policies being carried out by the governments and policies that the government should be carrying out, E-mail survey and General total scores. Each dot represents a policy/research priority.

52

Figure 5. Scatter plots between topics being investigated at national research centers and policies that the government should be carrying out, Colombia, Dominican Republic, El Salvador and Suriname. Each dot represents a policy/research priority

Figure 6. Scatter plots between topics being investigated at national research centers and policies that the government should be carrying out, E-mail survey and General total scores. Each dot represents a policy/research priority.

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59

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Fields Fields Content Main purpose Analysis Author Name of authors Identify the authors that have

been publishing on this issue Quantify if exists a pattern (Who is publishing more? On which specific approach?) and describe it

Year year of publication Identify temporal pattern Quantify and analyze if exists a pattern (e.g. increasing/decreasing, concentration in a specific period) and describe it

Title Paper Title Record NA Journal Journal's name Record NA Countries/Places Country or country region where the

study was conducted To apply the inclusion/ exclusion criteria Identify the countries that have publication in this field

Quantify and analyze if exists a pattern and describe it

Volume Journal information Record NA Issue Journal information Record NA Pages Pages interval Record NA Type of Article Study design: Empiric or Review -

Position paper Classify according to the type of study conducted


Affiliation of 1st author Name of the Institution of affiliation of the 1srt author

Identify the kind of Institution involved on this kind of publication


Target population Study focus: Population in General or Specific groups (for example - e.g. - elderly children, women, diabetes, indigenous people etc)

Classify according to the focus of study


60

Fields Fields Content Main purpose Analysis Year of data collection Year or period that was conducted the

data collection. If the paper is a review should be informed here the period covered by the review.

Identify the period of data collection


Objective Objective AND research question. Line break between these issues: Objective: Research question: Register this info here only when explicated by authors. If not, observe field “Research notes”

Identify and classify the objectives and the research questions

Quantify and analyze if exists a pattern and describe it. Analyze the research questions according to the main barriers found

Methodology Methodology applied in the study (etc), as classified by authors. Focus the general approach and/or data collect method (e.g. sectional study, observational, focus group, in depth interview etc). If not clear, copy from the Abstract the whole text related to the methodology.

Identify the more frequently used methodologies.

Quantify and identify the most frequent used methodologies approach. Analyze if exist a pattern and describe it. Demand side approach will be considered always the health system level corresponds to individual/ household/ community.

Main findings List the main results found (e.g. % of persons that doesn't receive all medicines). Identify and record here if any problem/ barrier to ATM was Highlighted by the author as a priority

Identify the main results found and link this information with the research

Analyze the main results found in order to identify the priority research questions

Main problems/Strengths

List the main problems/strengths related to ATM found (e.g. reason for persons did not receive all medicines) as stated by authors.

Identify the main problems/strengths and link this information with the research

Analyze the main results found in order to identify the priority research questions

Barrier ATM - health system level

Classify the access to medicines barriers according to Health System Level

Classify the access to medicines barriers according to Health System Level

Analyze the research questions according to the main barriers found

61

Fields Fields Content Main purpose Analysis Barrier ATM - WHO Framework

Classify the access to medicines barriers according to WHO-Framework

Classify the access to medicines barriers according to WHO-Framework


Keywords List the keywords as as stated by authors

Record NA

Abstract Field with the abstract Record NA Notes Field with specific research notes

Add any important information that is not addressed in other field

Help to complete the analysis with other information that was not previously identified during the matrix's elaboration process.

NA

Research Notes Record specific research notes (each one per paragraph) as: 1. Questions proposed by authors as deserving further investigation in following studies

Identify questions proposed by authors as deserving further investigation in following studies.


URL Electronic address (website) Record NA File Attachments To attach pdf file (if available) Record NA Language Identify the language the text was

writen. Identify the language of the paper was write

Count and Classify by language

NA - not applicable Record - the information help to catalog the paper not necessarily will be use in the analysis, if the case to characterize the general results

62

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Below are listed the sequential steps applied to perform the Bibliographic search:

1) perform the search in the databases using the key words selected

2) combine the results from all databases, clean up the double entries

3) apply the exclusion/inclusion criteria

4) to the selected papers, do the download of the full text

5) delivery the papers to the revisers

6) fill in excel file and apply the refined exclusion/inclusion criteria by the revisers

7) receive the excel file filed with the information if the paper was included or not in the revision process

8) match the endnote databases from the pair review

9) revise according with the criteria the 2 equivalents files

10) Choose the revision that better accomplish with the revision criteria, if the case

combine both in order to achieve this goal. a. Clean up the endnote file (exclude the double entries) b. Classify and adjust any field that was not clearly classified by the revisers

11) Generate de database in excel using a macro to export

63

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64

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MedLine - 980 ("pharmaceutical preparations"[MeSH Terms] OR "drugs, essential"[MeSH Terms] OR "drugs, generic"[MeSH Terms]) AND ("health services accessibility"[MeSH Terms] OR "health policy"[MeSH Terms]) AND ("humans"[MeSH Terms] AND (English[lang] OR Spanish[lang] OR Portuguese[lang]) AND ("2000/01/01"[PDAT] : "2010/09/30"[PDAT])) AND ("humans"[MeSH Terms] AND (English[lang] OR Spanish[lang] OR Portuguese[lang]) AND ("2000/01/01"[PDAT] : "2010/09/30"[PDAT])) Scopus - 594 (TITLE-ABS-KEY("access to medicines" OR "Medicines Price" OR "Rational use of medicine" OR "medicines affordability" OR "affordability of medicines" OR "accessibility of medicines" OR "medicines accessibility" OR "Medicines financing" OR "Availability of medicines" OR "medicines availability") AND SUBJAREA(mult OR agri OR bioc OR immu OR neur OR phar OR mult OR medi OR nurs OR vete OR dent OR heal OR mult OR arts OR busi OR deci OR econ OR psyc OR soci) AND PUBYEAR AFT 1999 AND PUBYEAR BEF 2011) ISI - 739 Topic=(access to medicines OR "Medicines Price" OR "Rational use of medicines" OR "medicines affordability" OR "affordability of medicines" OR "accessibility of medicines" OR "medicines accessibility" OR "Medicines financing" OR "Availability of medicines" OR "medicines availability") Refined by: Languages=( ENGLISH OR PORTUGUESE OR SPANISH ) AND Publication Years=( 2010 OR 2003 OR 2009 OR 2004 OR 2008 OR 2001 OR 2007 OR 2000 OR 2006 OR 2005 ) Lilacs - without duplicates - 47 Portuguese - 45 ((Preparações Farmacêuticas) OR (Medicamentos Essenciais) OR (Medicamentos Genéricos)) AND ((Acesso aos serviços de saúde) OR (Politica de Saúde)) em assunto (search for Mesh/Desc terms) Spanish - 33 ((Preparaciones Farmacéuticas) OR (Medicamentos Essenciales) OR (Medicamentos Genéricos)) AND ((Accesibilidad de los Servicios de Salud) OR (Política de Salud)) English - 44 ((Pharmaceutical Preparations) OR (Drugs, Essential) OR (Drugs, Generic)) AND ((Health Services Accessibility) OR (Health Policy))

65

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Dear Mr./Mrs., The Health Systems Research is essential to understanding, planning, monitoring and evaluating the interaction amongst different health system components. It aims to enhance the systems’ effectiveness in producing adequate health outcomes. In this process, access to medicines plays a fundamental role. The Center for Pharmaceutical Policies, a PAHO-WHO collaborating center in Brazil, was invited by the Alliance for Health Policy and Systems Research (AHPSR - WHO) to conduct a study that aims to identify policy priorities and information gaps concerning access to medicines in the America Region. As part of the methodology, we are consulting experts in the field by means of this electronic survey. We would like to invite you to collaborate with this project. In case of acceptance, you will be asked to perform the following steps:

1. Save the attached file in some directory on your computer. 2. Answer the questionnaire that attached n this with this email. The document attached

contains 20 pages and it takes around 30 minutes to be filled in. 3. Once fulfilled, the questionnaire should be sent back to us at [email protected] (this

account was created exclusively to this study). We kindly ask you to us your feed back in no more then 15 days. This timing is very important for the feasibility of the work and to guarantee the quality of its outcome. The outcomes of this project along with similar research efforts in other regions will guide the outline of a research priority agenda by AHPSR. We look forward to receiving your contributions. Best regards, Vera Lucia Luiza Research Coordinator Núcleo de Assistência Farmacêutica, ENSP/Fiocruz Rua Leopoldo Bulhões 1480/632, Manguinhos CEP.: 21041 210 - Rio de Janeiro RJ Tel. (21)25982591 Fax: (21) 2209-3076

Please confirm if you received this message!

66

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Dear Mr./ Mrs, On a previous email (see bellow), we invited you to collaborate with the research project “Identification of Priority Policy Research Questions on Access to Medicines in Low and Middle Income Countries in the American Region”. We’d like to confirm if you received the previous email and to emphasize the importance of your contribution for the success of this research. If you had any problem receiving or using the attached file, or if you have any doubt concerning your participation, please contact us on [email protected] and wee will be happy to help you. We look forward to receiving your feedback. Best regards, Vera Lucia Luiza Research Coordinator Núcleo de Assistência Farmacêutica, ENSP/Fiocruz Rua Leopoldo Bulhões 1480/632, Manguinhos CEP.: 21041 210 - Rio de Janeiro RJ Tel. (21)25982591 Fax: (21) 2209-3076

-./0"$#)1,)()02%()**+,)%

DearMr./Mrs., On behalf of the Center for Pharmaceutical Policies, I’d like to thank you for your valuable contributions to the project “Identification of Priority Policy Research Questions on Access to Medicines in Low and Middle Income Countries in the American Region”. Best regards, Vera Lucia Luiza Research Coordinator Núcleo de Assistência Farmacêutica, ENSP/Fiocruz Rua Leopoldo Bulhões 1480/632, Manguinhos CEP.: 21041 210 - Rio de Janeiro RJ Tel. (21)25982591 Fax: (21) 2209-3076

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-.(5% (5% #% A"5)$(*'(@"% 5'3AB% #(2(+<% '1% (A"+'(0B% *14()B% *$(1$('("5% #+A% (+01$2#'(1+%<#*5% )1+)"$+(+<% #))"55% '1% 2"A()(+"5% (+% '."% 62"$()#% D"<(1+,% '.$13<.% N"B9(+01$2#+'%(+'"$@("?5M%%In case of acceptance, participants are supposed to answer the following questionnaire on access to medicines, public policies and research in their countries. The selection of the interviewees was based on their relevant role and position in the field.

In our research reports and related publications, participants’ opinions shall not be associated to their names. It may not be possible to guarantee anonymity though. Since participants hold public positions in the field, their opinions might be identified.

Participants will neither receive any kind of financial support nor will have any authorial or publishing rights on the contents provided for the interview.

Participation is voluntary. Refusal to participate will not bring any negative consequence for people’s relationship with our institution.

The outcomes of this project along with similar research efforts in other regions will guide the outline of a research priority agenda by AHPSR. Additionally, data can be used in scientific publications such as master and doctorate thesis.

I agree with the above-mentioned terms and with my participation

___________________________________ March, ____ 2011

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90

If the person does not work in the MoH, go to Q 6. 2. Is there a health research priority document approved and in place in this

country? (If no, go to Q5)

3. When was the last update (month/year)? _____________________ If yes, ask for a copy and link.

4. What are the existing mechanisms to enforce/implement the health research agenda?

5. Do you consider that access to medicines is included in the health research agenda?

6. In your opinion, are there any recent examples (past 5 years) of scientific evidence use in decision-making regarding access to medicine policies?

7. If yes, could you please give an example?

91

8. What are the 3 most important criteria that should be applied when defining policy research priorities for access to medicines? (Please, pick the 3 most relevant items out of the following list and rank them according to their degree of importance. Note “1” to the most important item and “3” to the least important one in your selection. The other items should be left blank)

Items (proposed criteria)

Rank (from 1 to 3 in

order of importance)

a) Community concern/demand; Environmental health and sociopolitical effects

b) Feasibility (Capacity of the system to carry out the research; Funding support; Justification of the cost/investment; Justification of time)

c) Human rights issues; Equity focus; Ethical and moral issues

d) Impact on development; Economic impact

e) Partnership building; Research capacity building

f) Political will/ acceptability/ commitment

g) Relevance (Magnitude of the problem; Persistence of the problem; Impact on health; Urgency)

h) Responsiveness to the National Health Policy or national goals

i) Research utilization (Adequacy and usefulness of the current knowledge base (avoiding duplication); Applicability of the research outcome; Availability of cost-effective interventions (access); Operational effectiveness)

j) Other, specify:

In the next section, all questions are related to the dimensions of the WHO framework for access to medicines:

! Rational use and selection ! Price/affordability ! Reliable health system/ health system structure ! Sustainable financing

For each dimension, four questions will be asked:

! Policies being carried out by the government ! Policies that the government should be carrying out ! Topics being investigated at national research centers ! Research topics required for public health policies

For each question, you should select and rank from a predefined list the 5 most important policy/research topics.

Rational selection and use of medicines de medicamentos

92

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Thank you for your participation!

Entregar al entrevistado su copia del término de consentimiento

96

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Author Year Main findings VLL Topic Barrier ATM - health system level

Barrier ATM - WHO Framework

D. Beran and J. S. Yudkin

2010 It was found that the barriers to access to insulin were more to do with problems linked to distribution, tendering and government policies than purely accessibility and affordability issues.

Access individual, household and community level health sector

affordability sustainable financing reliable health system

S. Dal Pizzol Tda et al.

2010 It was found that 76.4%of medicines belonged to the Municipal EML (REMUME) and 63% from the WHO EML. Of all medicines prescribed, 76.1% were available in the inspected facilities; for essential medicines, the availability increased to 88.1%. Prescription in disagreement with the REMUME may result from the unavailability of medicines in the inspected facilities or the lists' inadequacy for the level of care

Access health sector reliable health system

V. M. V. Paniz, et al.

2010 Free access was higher in the Northeast state (62.4%) than in the South state. The strategy of the Family Health Program (Programa Saúde da Família - PSF) was more effective in providing access than the traditional model, with higher results in the Northeast (61.2%) than in the South (39.6%). The unavailability of medicines in SUS and lack of money to buy them were key determinants of a lack of access.

Access Public health service delivery channels Health sector

Affordability Reliable health system

V. J. Wirtz, G. Russo and M. D. Kageyama-Escobar

2010 The type of health service provider was found to be the most important predictors of access to medicines. Although the proportion of HSU obtaining a prescription and paying for drugs has broadly stayed the same as in 1994, the percentage of HSU paying for their prescribed medicines decreased from 70% in 1994 to 42% at Ministry of Health institutions in 2006. Conclusion. The progress in prescription and population access to medicines has been uneven across health service providers.

Access Public and private health service delivery channels Health sector

Rational selection and use Affordability

100



F. Doloresco and L. C. Vermeulen

2009 Nations in lower Human Development Index HDI categories were less likely to be able to easily obtain essential medicines (RR = 8.1), and only 80% of countries indicated that most hospitals do not use expired or outdated medicines. Compounding the potential for administering potentially unsafe medicines, only 63% of countries stored and tracked medicines in a manner that facilitates efficient and effective recalls in a majority of their hospitals.

Access Public and private helath service delivery channels

Reliable health system

I. C. M. Emmerick, V. L. Luiza and V. L. E. Pepe

2009 The availability of key medicines varied from 80.4% in to 61.2% in Brazil. The mainly results concerning the "percentage of completed prescriptions" varied from 1.1% to 98.6% "percentage of patients who know how to take their medicines" varied from 60.4% to 93.3%. Educational level showed to be an important predictor of knowledge on how to use medicines, especially relevant when prescription is completed.

Access individual, household and community Public and private health service delivery channels Health Sector

rational, selection and use reliable health sector

L. R. L. Pereira and O. de Freitas

2008 It was found that 61.2% of prescribed medidines were dispensed and 85.3% belonging to the List of Essential Medicines and only 18.7% of patients had fully understood prescription. The total time involved in dispensing was an average of 53.2 seconds.

Access Individual, household and community level;

Rational selection and use Reliable health system

A. Zambrano, M. Ramirez, F. J. Yepes, J. A. Guerra and D. Rivera

2008 There was an increase in preventive medical consultations in 2003 and a decrease in the use medical care for acute illness, due mainly to lack of money. Access to medicines increased from 1997 to 2003, as reflected by a decrease in out-of-pocket expenditure on medicines

Access Individual, household and community level Health sector

Affordability Reliable Health System

A. A. Guerra, et al.

2004 The availability of essential drugs in public facilities is low and varies widely, with the result that persons who need such drugs the most are often those who lack access to them. Private pharmacies are the main source of essential drugs.

Access Public and private health service delivery channels


C. P. Romero 2002 Exploring reasons why the patient could not take prescription drugs, finding the most frequent cause of drug exclusion cast offered at the pharmacy (67%)followed by the shortage of supply (11.5%) or because of the cost (7%), the latter again with significant differences between subregions (1.8% in La Libertad, and 11.5% Junan).

Access Public and private health service delivery channels Health Sector

rational selection and use Affordability reliable health system

101



A. Nunn, E. D. Fonseca and S. Gruskin

2009 Brazil's efforts to preserve its domestic AIDS treatment policies had far-reaching implications for global essential medicines policy. Brazil's reforms improved global transparency about drug prices, affirmed generic drug use to address public health needs, defined access to medicines as a component of the human right to health.

ARV International and local pharmaceutical sectors

Beyond the health sector

M. Flynn 2008 Three key factors led to the government becoming a direct producer of ARVs: 1) a pre-existing infrastructure of public laboratories that have served the public health system to a greater or lesser degree since the 1960s; 2) strong civil society pressures, including public health activists both inside and outside the government; and 3) a pharmaceutical sector characterized by high prices and controlled by transnational drug companies.

ARV Reliable Health System

Beyond the health sector

G. C. Chaves and M. A. Oliveira

2007 The Brazilian AIDS program provided 17 antiretroviral (ARV) medicines in 2007, but is currently facing serious financial problems because the cost of three patented ARVs (Efavirenz, Lopinavir/Ritonavir and Tenofovir) consumes over 60% of the Ministry of Health budget for HIV/AIDS medicines.

ARV Beyond the health sector

Affordability Sustainable financing

A. S. Nunn, E. M. Fonseca, F. I. Bastos, S. Gruskin and J. A. Salomon

2007 Brazil’s price negotiations have been most effective in lowering costs for drugs in which generic competition has emerged. Despite declining patented ARV prices, Brazil’s total HAART costs more than doubled since 2004. Cost increases reflect, in part, the progression of Brazil’s AIDS epidemic ten years after introduction of free and universal access to HAART: more people began treatment, the standard of care evolved, and new drugs became available for both treatment-naive and treatment-experienced patients.

ARV Public and private health service delivery channels

Affordability Sustainable Financing Reliable health system

L. S. Ritz, T. Adam and R. Laing

2010 Medicine selection, intellectual property rights, and monitoring and quality assurance were among the top topics studied over the last 10 years. Further analysis revealed that authors residing in Brazil tripled their previous contribution of four papers in 2002 to 12 in 2007.

General Individual, Household and Community Public an Private health service delivery channels Health sector

Rational selection and use Affordability Sustainable financing Reliable heath system

102



M. Aaserud, et al.

2005 Barriers to translate the findings of studies into policy are complex, multifactoral and context specific. Authors reported that difficulties were experienced in obtaining detailed information on drug availability and use at country level.

General individual, household and community level health sector

Rational selection and use reliable health system

E. S. Miranda, et al.

2009 For most medicines (71.4%), the availability of bioequivalent generics was less than 10%. In the private sector, the average number of different bioequivalent generic versions in the outlets was far smaller than the number of versions on the market.

Generic Public and private health services delivery channels


C. E. da Rocha, J. A. C. de Barros and M. D. P. Silva

2007 Is was found high level of knowledge and information from consumers concerning generic medicines (95.7% had heard of generic drugs, and 68.1% could define generic medication)

Generic Individual, household and community level Health Sector


M. Gossell-Williams

2007 Found a high acceptance of generic medicines by physicians in Jamaica. Nevertheless, 33% of the physicians were able to identify at least one case in the past year of clinical problems with generic substitutes that they perceived would not have occurred with the innovator

Generic public and private health service delivery channels health sector

Rational selection and use reliable health system

M. C. R. D. d. Carvalho, H. Accioly JÃºnior and F. N. Raffin

2006 Investigation on representation of generics medicine to consumers found as central nucleus are related to categories as price, quality, and pharmaceutical equivalence, while the peripheral system was represented by the categories option, effectiveness, government, social benefit, and accessibility

Generic Individual, household and community level Health sector

Rational selection and use Affordability Reliable health system

C. R. C. Dias and N. S. Romano-Lieber

2006 Generic medicines quickly gained considerable space in the Brazilian pharmaceutical market. Ongoing adaptation of the legislation, media support, and the government’s involvement in spreading the policy were key success factors. The population’s access to medicines did not increase significantly, but people can now purchase medicines at more affordable prices and with quality assurance and interchangeability.

Generic health sector reliable health system

F. S. Vieira and P. Zucchi

2006 The generic medicines were introduced on average at prices 40% lower than the innovator ones and this difference tended to increase over the years. The price difference between generic and innovator medicines increased in the subsequent four-year period after generic launching in 68%.

Generic health sector affordability reliable health system

103



N. Homedes and A. Ugalde

2005 The term generic means different things between and within countries, which have implications on tests that each pharmaceutical product should undergo in order to be considered to have met acceptable efficacy and safety standards.

Generic Beyond the health sector

Rational selection and use

W. M. Monteiro, et al.

2005 Most of generic options were not available in private pharmacies. Generic Public and private health services delivery channels


A. L. Chieffi and B. R. d. C. Barradas.

2010 A small number of attorneys is responsible for the largest number of lawsuits filed to obtain these drugs. The finding that more than 70% of the lawsuits filled for certain drugs are the responsibility of one single attorney, may suggest a close connection between this professional and the manufacturer.

Lawsuit Beyond the health sector

Reliable health System

V. L. E. Pepe, et al.

2010 In 80.6% of the 98 suits in which the specific medicines could be identified, at least one drug did not belong to any publicly funded list of medicines.

Lawsuit Health sector Sustainable financing reliable health system

J. R. Pereira, R. I. dos Santos, J. M. do Nascimento and E. P. Schenkel

2010 About 40% of medicines requested by law suit were on the State level EML (RESME).

Lawsuit health sector Sustainable financing reliable health system

M. Ventura, L. Simas, V. L. E. Pepe and F. R. Schramm

2010 Injunction was granted in full to 78.5% of drugs requested. In 96.9% of decisions regarding the injunction, the judge makes no requirement for the grant or maintenance of the injunction request, solidifying its conviction only on the documentation submitted by the claimant.

Lawsuit Beyond the health sector


A. L. Chieffi and R. B. Barata

2009 Most cases of lawsuits were filed through private attorneys; 47% of the patients had obtained their prescriptions through private care; and 73% of the cases involved patients from the three wealthiest areas in the city of Sao Paulo. The data demonstrate that such legal action violates key principles of the SUS such as equity, thereby privileging individuals with higher purchasing power and more access to information.

Lawsuit beyond the health sector

reliable health system

G. E. M. Kornis, M. H. Braga and C. E. F. Zaire

2008 It was found regulation enforcement on the pharmaceutical field in Brazil, with 47 acts published after 2000. The government is strengthening efforts to improve availability of medicines.

Lawsuit Health sector Reliable Health System

104



S. B. Marques and S. G. Dallari

2007 In 96.4% of the cases analyzed, judges' discourse sentenced the State. Lawsuit Health sector Sustainable financing

F. S. Vieira and P. Zucchi

2007 The majority of demands for drugs that have led to legal proceedings could be avoided if two SUS directives were followed, namely the organization of oncology services and the observance of reporting on essential medicines. Failure to do so causes a breakdown in the National Drug Policy, in equality of access and in the rational use of drugs within the National Health System.

Lawsuit Public and private health service delivery channels Beyond the health sector

reliable health system

H. V. Hogerzeil, M. Samson, J. V. Casanovas and L. Rahmani-Ocora

2006 Were identified and analyzed 71 court cases from 12 countries in which access to essential medicines was claimed with reference to the right to health. In 59 cases, access to essential medicines as part of the fulfillment of the right to health could indeed be enforced through the courts, with most coming from Central and Latin America. Success was mainly linked to constitutional provisions on the right to health, supported by the human rights treaties. Other success factors were a link between the right to health and the right to life, and support by public-interest non-government organizations. Individual cases have generated entitlements across a population group, the right to health was not restricted by limitations in social security coverage, and government policies have successfully been challenged in court. In several countries, the court cases have led to a general, availability of antiretroviral treatment for HIV/AIDS patients. In 14 cases from six countries the judgment was extended to other individuals in similar situations. The constitutional guarantees on access to health care services should be well defined, for example through reference to a national list of essential medicines, to prevent abuse.

Lawsuit Health Sector Beyond the Health Sector


A. M. Messeder, C. G. S. Osorio-de-Castro and V. L. Luiza

2005 The prescriptive pattern of non EML medicines have been resulting in lawsuits for these medicines, which have been forcing the inclusion of these products in the public financing lists unregardling criteria as scientific evidence of efficacy or safety.

Lawsuit Health sector Sustainable financing

105



J. M. Madden, et al.

2010 Medicines price study methodology showed to be valid in Peru. Method Individual, household and community level Public and private health service delivery channels

Affordability Realiable health system

V. M. V. Paniz, et al.

2010 The standardization of medicine access indicators and the definition of appropriate recall periods are required to evaluate different medicines and access dimensions, improving studies comparison.

Method individual, household and community level

rational selection and use

TA. D. Bertoldi, et al.

2008 It were found problems with data on the reliability and validity of medicines use. Questionnaires are rare and it is uncertain if the instruments currently in use are accurately assessing the construct of medicine utilization.

Method individual, household and community level,

rational selection use

M. M. L. De L. Horst and O. Soler

2010 The initiative to unify the purchase of medications for all participating countries to improve pricing and purchasing management resulted in large-scale savings.

MP health sector reliable health system

A. Gertner 2010 The article shows that, in performing economic analyses, company employees sought to locate/construct from known/measured parameters, a need/demand for the drug within the public system, thus creating a market. Uncertainty is not merely an incidental obstacle of the company’s work but a core feature of its practice. The strategic use of uncertainty allows for the displacement of public health priorities by commercial interests and the supplanting of what is sensibly sound by what is methodologically permissible.

MP Beyond the health sector


D. P. Lyra, B. J. Balisa-Rocha, A. R. Mesquita and C. E. da Rocha

2010 Among the 68 leaflets analyzed, most did not contain all the information required by the specific regulation.

MP Beyond the health sector


R. Bernztein and I. Drake

2009 it was possible to create a public program to provide a basic basket of medicines free of charge. Even with problems of effectiveness (27.8% coverage in under 5 years old) the programa showed to be equitable, reaching largest coverage in the poorest provinces and efficient (6.46 U.S. per life saved)

MP Individual, household and community level Health Sector

Rational Selection and Use Affordability

106



J. O. Rivera, M. Ortiz and V. Cardenas

2009 One-third of adult residents of El Paso and 5% of those in Ciudad Juarez reported crossing the border to purchase medications (P < .001). Lack of health insurance in the United States was associated with crossing the border to purchase medications. Nine percent and 7% of US residents traveled to Mexico seeking dental and medical care,

MP Individual, household and community level Health sector

Rational selection and use affordability reliable health system

P. Moise and E. Docteur

2008 In 2004, Mexico has spent just under 14 million dollars (1.3% of GDP) in pharmaceuticals, more than most OECD countries. Public sector expenditure on pharmaceuticals as a percentage of total expenditure on these products was 8.2% in 2002, 10.4% in 2003 and 11.6% in 2004.

MP Public and Private health service delivery channels


E. Seoane-Vazquez and R. Rodriguez-Monguio

2008 Public expenditures on drugs and medical supplies represented 0.8% of Guyana's GNP in 2002 and increased to 1.0% of the GNP in 2003. Expenditures for drugs and medical supplies represented 29.0% of the MoHs total expenditures in 2002 (Ministry of Health, 2004).

MP Public and private health service delivery channels Health Sector

Sustainable Financing Reliable health system

V. J. Wirtz, M. R. Reich, R. L. Flores and A. Dreser

2008 The ‘studies on access to medicines show that, first, drug prices in Mexico are higher than in many developed countries when adjusted for income. The four policy related problems highlighted by the systematic review were: irrational prescribing, harmful self-medication, inequitable access, and frequent drug stock shortage in public health centers. This review identified two priorities for Mexico's pharmaceutical policy and strategies: tackling the irrational use of medicines and the inadequate access of medicines. These are critical priorities for a new national pharmaceutical policy

MP Public and private health sector delivery channels Health sector


N. Homedes and A. Ugalde

2006 Currently, 80% of all the medicine units marketed in the country are locally produced, and Brazilian companies account for 75% of the total sales value. Patients follow-up is compromised by the limitations of the public health system

MP Public health service delivery channels Health sector

Rational selection and use Sustainable financing

N. Homedes, A. Ugalde and J. R. Forns

2005 Most social security institutes use formularies that contain many more drugs than those in the essential drug lists, and the institutes spend much more on pharmaceuticals than do the ministries of health. Within the health ministries, hospitals and health centers purchase drugs not included on the list directly from wholesalers and retailers. As a result, the benefits obtained from the use of these lists have been limited.

MP Public and private health service delivery channels Health sector Beyond the health sector

Rational selection and use Reliable Health System

107



S. Mejia Restrepo, et al.

2002 Most of the institutions experience problems in distributing the medicines listed under the Mandatory Health Plan, a low percentage of medicines is dispensed at zero cost, and a major portion of patients purchase medicines through associations of diabetics or rely on alternative medicine. Several obstacles to equity in health care coverage and access to essential medicines. Does not exist self-medication control.

MP Public and private health service delivery channels Health sector

Rational selection and use Reliable health System

S. Ratanawijitrasin, S. B. Soumerai and K. Weerasuriya

2001 It was found a diversity of mechanisms to modify the degree of access to a drug.

MP Health sector Rational selection and use Reliable Health System

M. A. E. Cosendey, et al.

2000 The implementation of health sector reform in Brazil in the pharmaceutical system implied on changing a strongly centralized model to a decentralized one. During transitional period three states developed their own program, apart of the model proposed by the federal level.

MP health sector rational selection and use reliable health system

A. Ceron and A. S. Godoy

2009 In low-income countries, as stronger is IP protection more import it is as barrier to access to medicines. The number of low-income countries writing national legislation to protect IP for pharmaceutical products is growing worldwide, trends suggest that industrialized countries and the pharmaceutical industry are using more tactics than just trade agreements to push for increased IP protection and that the process of national legislation is a valid arena for confronting public health needs to those of the industry.

Patent beyond the health sector

rational selection and use affordability sustainable financing reliable health system

A. Attaran 2004 Only 19 of 319 items of WHO_EML have basic post dating 1 Apr 1982, which means that only these ones might still be patented in developing countries. Pharmaceutical companies usually did not seek patents in developing countries, even when they legally had the option. Despite stating that patents protection does not affect access to essential medicines in general, mainly generic versions, authors call attention that important groups of EM, as ARVs, are under patent protection.

Patent Public and private health service delivery channels Beyond the health sector


108



M. A. Oliveira, J. A. Z. Bermudez, G. C. Chaves and G. VelÃ¡squez

2004 The countries included in this study have not been incorporating into their legislation all of the advantages that the TRIPS Agreement can provide.

Patent Beyond the Health Sector


C. F. Pires, M. M. Costa, D. Angonesi and F. P. Borges

2006 Consumers did not know the concept of 'pharmaceutical care'. Perception Individual, household and community level Health sector


M. C. Moss and J. R. S. McDowell

2005 Non-prescribable medicines were believed by participants to be efficacious. Conventional medication was perceived as an access to medical care. Study findings may be relevant to other rural populations with strong social and religious mores.

Perception Individual, household and community level


J. C. R. Ferreira-Filho, G. T. Correia and P. D. C. Mastroianni

2010 No facilities had all essential key medicines. Generic had lower price then reference medicines.

Price public and private health service delivery channels health sector

affordability reliable health system

C. D. S. Pinto, et al.

2010 Availability of the reference (4.0%) and branded generic (16.0%) versions of metformin was low; however, this availability of the generic version was 80.0%, contrasting with the availability of generic versions of the remaining medicines, which was non-existent.

Price public and private health service delivery channels health sector


A. Cameron, M. Ewen, D. Ross-Degnan, D. Ball and R. Laing

2009 In the Americas, mean availability in the public sector was lower than in the private sector in all regions.

Price public and private health service delivery channels, health sector

affordability, sustainable financing, reliable health system

S. Barberato Filho and L. C. Lopes

2007 Markup for branded generics selling is much higher (147-236%) than for non branded generics (98-199%) which is higher than for reference medicines (44-57%).

Price Public and private health service delivery channels Beyond thehealth sector

Reliable health system Rational selection and use

109



M. G. Lima, A. Q. Ribeiro, F. D. A. Acurcio, S. Rozenfeld and C. H. Klein

2007 Mean drug expenditures per month were US$38.91. The therapeutic groups representing the majority of drug expenditures were: cardiovascular system (26%), nervous system (24%), and digestive/metabolic system (15%). Considering drug registration categories, brand-name drugs accounted for the majority of expenditures (54%). The results of this study can support policies to improve both access to medicines and overall health conditions for the Brazilian elderly population

Price Individual, household and community level

Affordability

S. Mendis, et al. 2007 In all countries < 7.5% of these 32 medicines were available in the public sector, except in Brazil, where 30% were available, and Sri Lanka, where 28% were available. Median price ratios varied substantially, from 0.09 for losartan in Sri Lanka to 30.44 for aspirin in Brazil. One month of combination treatment for coronary heart disease cost 5.1 days' wages in Brazil; The cost of one month of combination treatment for asthma ranged from 1.3 days wages in Bangladesh to 9.2 days wages in Malawi. The cost of a one-month course of intermediate-acting insulin ranged from 2.8 days wages in Brazil to 19.6 in Malasia , even treatments that seem to be affordable are out-of-reach of a large number of people.

Price Public and private health services delivery channels


O. d. T. Nóbrega, et al.

2007 For the 132 drugs that were listed on both Brazil's and Sweden's lists, unitary retail prices in Brazil were 1.9 times higher. The high ratio between private retail and international-bulk price data suggests that the public-interest procurement and distribution systems called for by the Brazilian Health Policy, although only partially implemented (24), may offer the most cost-effective method for guaranteeing access to essential drugs.

Price Public and private health service delivery channels health sector

Affordability

G. C. Beckhauser, J. M. De Souza, C. Valgas, A. P. Piovezan and D. Galato

2010 Self-medication is a common practice in the surveyed population, especially among children up to seven years of age and conducted primarily by mothers. Convenience was the most reported reason for self-medication.

Self medication

Individual, household and community level


110



E. A. de Oliveira, A. D. Bertoldi, M. R. Domingues, I. S. Santos and A. J. D. Barros

2010 Frequency of self-medication increased with age, reaching 11%, 26%, and 34% at three, 12, and 24 months, respectively As age increased, there was a reduction in the total number of medicines used and an increase in self-medicine. Regarding the form of acquisition, more than 80% of medicines used were purchased using private resources, and approximately 10% were obtained for free through SUS. Regarding regularity, sporadic use was predominant in all follow-ups, and increased gradually from three to 24 months. Frequency of continuous use, on the other hand, fell by roughly 50% from three to 24 months.

Use individual, household and community level

rational selection and use

M. E. Herce, J. A. Chapman, A. Castro, G. GarcÄ±Âá-Salyano and K. Khoshnood

2010 One-third of health promoters have access to manage anti TB antibiotics (32%) and half have experience with their administration; 55% complement their biomedical treatments with traditional Mayan medicinal plant therapies in caring for their patients.

Use individual, household and community level


B. Schmid, R. Bernal and N. N. Silva

2010 Free access to medicines was shown to be a protective factor for self-medication. The distribution of medicines and appropriate health care should be considered when providing patient counseling and for reducing health risks from irrational medicine use.

Use Individual, household and community level


A. D. Bertoldi, A. J. D. d. Barros, A. Wagner, D. Ross-Degnan and P. C. Hallal

2009 In a primary health care program in Brazil almost 90% of the medicines prescribed by PSF physicians were provided for free. Women were more likely to use medicines than men. Except for relatively high use in children age 4 years or less, prevalence of medicine utilization increased with age. Analgesics, and anti-inflammatory products, followed by medicines to treat hypertension, were the most frequently used. One-third of the medicines used were prescribed by PSF physicians and just over 50% were used to treat acute health problems.

Use individual, household and community level health sector


111



C. Kauffmann, et al.

2009 The users of the public pharmacies were mainly female and individuals with low educational level and income. On average, 2.41 drugs were prescribed per medical prescription and 1.72 of these were procured. Out of the total medicines prescribed, 76.5% were listed in the municipal standard drug list (SDL). Medication was prescribed by its generic name in 81.8% of the prescriptions. Antibiotics and injections were prescribed in 11.9% and 4.0% of the prescriptions, respectively. Users’ access to information is partial, which can impair adherence to the treatment.

Use Health sector Rational selection and use

C. Kristiansson, et al.

2009 The poorest seek less care from health professionals for non-severe illnesses as well as for severe illnesses. Treatment with antibiotics is lacking for illnesses where it would be indicated. Caregivers are frequently paid for health services as well as antibiotics, even though all children in the study qualified for free health care and medicines. The implementation of the Seguro Integral de Salud health insurance must be improved.

Use Public health service delivery channels Health sector


D. B. Santos, M. L. Barreto and H. L. Coelho

2009 Most used pharmacological groups were: analgesics/antipyretics 25.5%), systemic antibiotics (6.5%), and anti-cough /expectorant drugs (6.2%). In the multivariate analysis, factors determining greater drug use were: age (four to five, six, seven to eight years); female sex; white mother; poorer health perception; interruption of activities due to health problems and health care, whether ill or not, in the last 15 days; drug spending in the last month; and medical visits in the last three months.

Use Individual, Household and community level


E. R. Vinholes, G. M. Alano and D. Galato

2009 Health education activities conducted by pharmacists collaborated to reinforce that the health team role is not only to allow an access to medicine, but also to guarantee its correct use.

Use Individual, household and community level Public health service delivery channels


C. R. Maldaner, M. Beuter, C. M. Brondani, M. L. BudÃƒÂ! and M. R. Pauletto

2008 Nine factors were found to influence adherence to treatment: team trust, support nets, educational level, accepting disease, treatment side effects, lack of access to medicines, long-term treatment, complex therapeutic approach, and lack of symptoms

Use Individual, household and community level Public and private health services delivery channels Health Sector

Rational selection and use affordability Realible health system

112



J. Maurer 2008 Health insurance coverage as the clearly dominating factor for explaining medication treatment take-up.

Use Individual, household and community level Health sector


V. M. Paniz et al.

2008 Prevalence of access to continuous- use medicines was 81% in non-elderly adults and 87% in the elderly.

Use individual, household and community level Public and private health service delivery channels

Rational selection and use health sector reliable health system

J. A. B.-. Rodriguez, et al.

2008 This analysis led to identifying medications whose formulation frequency did not correlate with an epidemiologic profile as immunomudulator and growthhormone (somatotropin) agents. There were differences in the frequency and quantity of DDD medications authorizedp by type of affiliation which could thus be providing evidence of obstacles to the population having access to drugs/medicaments.

Use Health sector Affordability Reliable health system

A. Ducati Luchessi, et al.

2005 From over the counter medicine advertised 3.6% have not been registered by ANVISA and also that 17.5% of the advertisings have not informed about their main side effects (Article 3, item I). It has also been stated that the analyzed material stimulated and/or induced the indiscriminate use of medicines whose consumption demands a prescription and that 38.5% of sale campaigns of medical prescription products did not have the registry number from the Health Ministry.

Use Individual, household and community level beyond health sector

rational selection and use reliable health system

J. L. Fiedler and J. B. Wight

2000 While in 93% of cases the types of medicines prescribed were appropriate, considering the signs and symptoms presented, in only 45% of cases were medicines prescribed in adequate doses and quantities. Eighty-two percent of respondents indicated that they had obtained assistance from their local Fund in the previous year, and 97% of these reported that the treatment received was `good'. However, in about 20% of respondents' visits, the Community Drug Fund did not always have the medicines required.

Use Individual, household and community level Health sector

Rational selection and use Affordability Sustainable Financing Reliable health system

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113

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Text totally taken from Dominican Republic Pharmaceutical Assessment Levell II Report - 2010

Country Context

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Unemployment

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115

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Health Sector

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116

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Pharmaceutical Sector

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117

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Regulation system

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118

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Medicine Financing

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Rational Medicine Use

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119

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Tabla 1 – Country´s general profile General data

Land extension (km2) 48,670,821 Income level Middle2 Urban population (%) 63,61 Poverty (%) 152 Extreme poverty (%) 7,52 Population 9,615.0003 Human development index (%) 0,7792 Gini coefficient (%) 0,522 Basic education coverage (%) 904 Dropout rate (%) 8,94 Public Investment in Education (%) of GDP 2,84 Gross National Income ($Dol-Int) 5,5503 Life expectancy at birth for men (years) 663 Life expectancy at birth for women (years) 743 Probability of dying before age five (per thousand live births)) 293 Probability of dying between 15 and 60 years for men (per 1000 inhabitants) 2753 Probability of dying between 15 and 60 years for women (per 1000 inhabitants)

1383

Healthy life expectancy at birth in men 573 Healthy life expectancy at birth in women 623 Male urban population (%) 60,25

Female urban population (%) 63,45 Men over 60 years (%) 2,975 Woman over 60 years (%) 3,015 1Observatorio Farmacéutico de las Américas. Secretaría de Estado de Salud Pública y Asistencia Social (SESPAS) 2004. 2Programa de las Naciones Unidas (PNUD)2005. 3Organización Mundial de la Salud 2006 Estadísticas Sanitarias Mundiales 2008 4Banco Interamericano de desarrollo (BID) Plan Decenal Metas de Ejecución 2000-2005. 5Monitoreo y análisis de los procesos de cambio y reforma OPS marzo 2007.

Tabla 2 – Health indicators Health indicators Valuer Public expenditure on health as (% GDP) 1,23 Out-of-pocket spending for the (%) of private health expenditure 70,83 Out-of-ocket spending for the (%) of total health expenditure 47,93 Average household spending $ U.S. 933 Total expenditure on health as (% GDP) 63 Total expenditure on health per capita US. $ 4493 Specialized hospitals 61 Municipal hospitals 1071 Provincial hospitals 221 Rural clinics 6151 Medical Clinics 901 Health Centers 301 Offices 1591 Public health facilities and private 30001 First-level (% of total) 851 Population that goes to public services (% of total) 531 Population that goes to a clinic or private (% of total) 341

120

Tabla 3 – Pharmaceutical sector indicatrors Indicator Value Health sector budget allocated to medicines (%). 9,41

Number of physicians per 10,000 population. 101

Number of pharmaceutical manufacturers and / or traders 4,8121

Number of laboratories manufacturing 1051

Number of distributors 1,3051

Number of private outpatient pharmacies 3,3001

Number of public hospital pharmacies 511

Number of public outpatient pharmacies 4171

121

0#(1'#2'3"4(

Background

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Health Sector

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122

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Pharmaceutical Sector

J.(G'.1'0"4(+'5/(3:*(="4.0k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c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l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

123

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124

1/4&*'$-(

Text totally taken from Suriname Pharmaceutical Assessment Levell II Report - 2010

Country background6

A:*( 3"3'.(+"+,.'3$"%("6(G,4$%'#*( $/('-",3(KWH(LHW( <&*%/,/(HDDK?8(G,4$%'#*( $/(."&'3*0( $%( 3:*( %"43:( "6( G",3:( 9#*4$&'( '%0( $/( +'43( "6( 3:*( 9#'>"%$'%( A4"+$&'.()'$%6"4*/3(<E$2,4*(R?8(A:*($%:'-$3'%3/(.$1*("%('%('4*'("6('-",3(RMK7DDD(O#H(64"#(=:$&:(#"/3(-*."%2/(3"(3:*(/"(&'..*0($%3*4$"4("6(3:*(&",%3458(Q3($/(0$1$0*0($%3"(RD(0$/34$&3/8(A:*( 3"3'.( +"+,.'3$"%( $/( KWH(LHW( <&*%/,/( HDDK?h( */3$#'3*0( '/( CRN(DCH( $%( HDDL(<ZUG?7(=$3:( 3:*(#';"4$35("6( 3:*(+"+,.'3$"%( .$1$%2( $%( 3:*(,4-'%(&"'/3'.('4*'8(A:*(+"+,.'3$"%( &"%/$/3/( "6( /*1*4'.( *3:%$&( 24",+/7( =:$&:7( *@&*+3( 6"4( 9#*4$%0$'%/7(:'1*(-**%(-4",2:3(64"#(0$66*4*%3(&",%34$*/("6(#'$%.5(964$&'('%0(9/$'8(

Figure 7. Geographic location of all districts of Suriname.

Source: Suriname Statistics Bureau (2009)

6 Information in this section comes from the following sources:

• Ministry of Health • General Bureau of Statistics of Suriname • Government of Suriname • UNICEF • UNDP

125

Table 15. Distribution of the Suriname Population, Census 2004+) Districts by Urban/Rural/Interior Inhabitants per district % 1 Paramaribo (Capital) Urban 242 946 49.2 2 Wanica Urban/Rural 85 986 17.4 3 Para Rural/Interior 18 749 3.8 4 Marowijne Rural/Interior 16 642 3.4 5 Commewijne Rural 24 649 5.0 6 Saramacca Rural 15 980 3.2 7 Coronie Rural 2 887 0.6 8 Nickerie Urban/Rural 36 639 7.4 9 Brokopondo Interior 14 215 2.9 10 Sipaliwini Interior 34 136 6.9 All districts 492 829 100 +) Health Care Situation in Suriname, Basic indicators and related health related Millennium Development Goals, Maltie

Mohan-Algoe, March 2006, National Health Information System, Ministry of Health. (G,4$%'#*( $/( '(#$00.*( $%&"#*( &",%345(=$3:( '(Z4"//(!"#*/3$&(X4"0,&3( <Z!X?("6('-",3( FG`( C7LKD( +*4( &'+$3'( <Z*%*4'.( U,4*',( "6( G3'3$/3$&/( _( ZUG?8( A:*4*( $/( %"(4*&*%3(0'3'('1'$.'-.*(3"(*@+4*//(3:*(4'3$"("6(3:*(+"+,.'3$"%(.$1$%2("%(.*//(3:'%(FG(`Rg0'5( "4( FG( `Hg0'58( 9&&"40$%2( 3"( 3:*( F%$3*0( I'3$"%( !*1*."+#*%3( X4"24'#(<FI!X?7(P,#'%(!*1*."+#*%3()*/",4&*7(3:$/(='/(RC8CM('%0(HN8HM(4*/+*&3$1*.5($%('(5*'4(+4*&*0$%2(3:*(+*4$"0("6(HDDD_HDDN8(9&&"40$%2( 3"( 3:*(#"/3( 4*&*%3( %'3$"%'.( &*%/,/( "6( HDDK7( 3:*( '1*4'2*( %,#-*4( "6(+*"+.*(+*4(:",/*:".0($/(6",48(A:*(+"1*435(.$%*(+*4(:",/*:".0($/(FG(`CKD8K(<ZUG?8(^6(3:*(3"3'.(.'-"4(6"4&*7('++4"@$#'3*.5(RBS('4*(,%*#+."5*07(=$3:(WS("6(3:*/*($%('(/3'3*("6(."%2_3*4#(,%*#+."5#*%3($%(HDDL(<ZUG?8((Z*%*4'.(0'3'('4*(/,##'4$>*0($%(A'-.*(H8(

Table 16. General profile of Suriname.

Aspect Indicator Source Year Population 492 829 census GBS*) 2004 % rural population 27,68 SAMICS*) 2006 % women 49.7 Census

GBS*) 2004

% under 5 yrs 10.5 census GBS 2004

General data

% over 60 yrs 8.6 census GBS 2004 DHI 0,769 HDR*) 2009 GDP US$ 2.773billion GBS 2008 est GDP per capita US $ 5840 GBS 2008 % under Poverty line n.a. Unemployment rate 13% census GBS 2008

Socioeconomic data

Literacy rate (age 15 and over can read and write) %

90.4 HDR 2009

Infant mortality rate 19.4 MOH*) 2007

126

Aspect Indicator Source Year Infant mortality rate 19.4 MOH*) 2007 General health

data Life expectancy in years of the population over 60 years

69.9 MOH 2008

*) SAMICS, Suriname Appendices Multiple Indicator Cluster Survey: HDR, Human Development Resource; MOH, Ministry of Health; GBS, General Bureau of Statistics

Health sector

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Table 17. Health care facilities in Suriname

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127

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*) 1. Primary; 2. Secondary; 3. Tertiary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

Table 18. Population by medical plan (mode of paying for health expenditure) +)

Medical Plan Number of persons covered %

Ministry of Social Affairs - Medical Plan 114,740 23.3 SZF (State Health Insurance Company) Medical Plan 105,074 21.3 Out of pocket payment 93,342 18.9 Company Medical Plan 49,396 10.0 Medical Mission Medical Plan 30,657 6.2 Private Insurance company Medical Plan 17,070 3.5 Other 4,484 0.9 Do not know 76,557 15.5 Not reported 1,509 0.3 Total population of Suriname, 2004 492,829 ;<(P*'.3:( \'4*( G$3,'3$"%( $%( G,4$%'#*7( U'/$&( $%0$&'3"4/( '%0( 4*.'3*0( :*'.3:( 4*.'3*0(V$..*%$,#(!*1*."+#*%3(Z"'./7(V'.3$*(V":'%_9.2"*7(V'4&:(HDDM7(I'3$"%'.(P*'.3:(Q%6"4#'3$"%(G5/3*#7(V$%$/345("6(P*'.3:(

(

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Box 3. Ten leading cases of death in Suriname (2007)

1. Cardiovascular diseases ( incl. Cerebrovascular diseases)

2. External causes of death: Accidents, violence and injuries, homicide,

suicide

3. Malignancies

4. Diseases originating in the Perinatal Period

5. Diabetes Mellitus

128

6. HIV / AIDS

7. Acute Respiratory infections

8. Diseases of the Urinary tract

9. Liver cirrhosis and other chronic Liver diseases

10. Congenital disorders.

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Pharmaceutical sector

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National Medicines Pharmaceutical Policy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a((

129

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

Regulatory system J@$/3$%2(#*0$&$%*/( .*2$/.'3$"%( $/(-'/*0("%(3:*(X:'4#'&*,3$&'.(9&3("6(RLWM(<Q$*&(3& #$& +,*($4$","8& 92"& #$& 2%*)$",R6$%$,#S+")*T& U(+9$%"$+%& 92"& A+%,"21$& RLWM?7(=:$&:( :'/( -**%( 4*1$/*0( '%0( '#*%0*0( -5( "3:*49&3/( '%0( !*&4**/( '%0(/,++.*#*%3*0(-5(/+*&$6$&()*2,.'3$"%/8(A:*(#"/3($#+"43'%3('#*%0#*%3/('4*(3:*(Z"1*4%#*%3(^40*4("6(HW(!*&*#-*4(RWLD7(*%6"4&$%2(3:*(+4"1$/$"%/("6(3:*(X'&O*0(V*0$&$%*/(9&3("6(RWNB('/(+*4(R( b'%,'45(RWLR('%0( 3:*(Z"1*4%#*%3(^40*4("6(BR(V'4&:(RWWW(<V$)5+,*&W$82*,$9$&L,R)*?7(.$-*4'.$>$%2($#+"43/(=:$.*('3(3:*(/'#*(3$#*(4*Y,$4$%2($#+"43(&*43$6$&'3*/(6"4(#*0$&$%*/8([*2'.(+4"1$/$"%/(4*Y,$4$%2(34'%/+'4*%&5h('&&",%3'-$.$35('%0(+4"#"3$%2('(&"0*("6(&"%0,&3( $%( 4*2,.'3"45( ="4O( '4*( %"3( $%( +.'&*8( A:*( 4*2,.'3"45( 6,%&3$"%/( '4*(+*46"4#*0( -5( 0$66*4*%3( ,%$3/( "6( V$%$/345( "6( P*'.3:7( =:$&:( &",.0( +4"1$0*($%6"4#'3$"%("%(.*2$/.'3$"%7(4*2,.'3"45(+4"&*0,4*/7(+4*/&4$-$%2($%6"4#'3$"%(</,&:('/( $%0$&'3$"%/7( &",%3*4( $%0$&'3$"%/7( /$0*( *66*&3/7( *3&8?7( ',3:"4$>*0( &"#+'%$*/7('%0g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m,'.$35(\"%34".(3*/3$%2(3:'3($/(+'43("6(A:*(V$#%,R4&

130

U$"$$)1,##$5$"& X((%Y,$","8& A+%,"21$( <UZjG7( V*0$&$%*/( G,++.5( \"#+'%5(G,4$%'#*?8( Q%(HDDW7(BND( /'#+.*/(=*4*( 3'O*%( 6"4(Y,'.$35( &"%34".( 3*/3$%28(^6( 3:*(/'#+.*/(3*/3*07(H(6'$.*0(3"(#**3(3:*(Y,'.$35(/3'%0'40/N8(([*2'.( +4"1$/$"%/( '4*( $%( +.'&*( 6"4( .$&*%/$%2( '%0( +4*/&4$-*4/l( '%0( +:'4#'&$*/l(+4'&3$&*/8(X4*/&4$-$%2(-5(2*%*4$&(%'#*($/(%"3(#'%0'3"45($%(3:*(+,-.$&('%0(+4$1'3*(/*&3"48(A:*4*($/(%"3(/+*&$6$&(4*2,.'3$"%/("%(/,-/3$3,3$"%('%0($3($/(+*46"4#*0(-"3:($%( +,-.$&( '%0( +4$1'3*( +:'4#'&$*/8( A:*4*( '4*( %"( $%&*%3$1*/( 3"( 0$/+*%/*( 2*%*4$&(#*0$&$%*/('3(+,-.$&("4(+4$1'3*(+:'4#'&$*/8(A:*4*( '4*( +4"1$/$"%/( $%( 3:*( #*0$&$%*/( .*2$/.'3$"%( &"1*4$%2( +4"#"3$"%( '%0g"4('01*43$/$%2("6(#*0$&$%*/7(-,3(3:*5(:'1*(%*1*4(-**%(*%'&3*0('%0($#+.*#*%3*08(

Medicines supply system X,-.$&( /*&3"4(#*0$&$%*/(+4"&,4*#*%3( '%0(0$/34$-,3$"%( '4*( 3:*( 4*/+"%/$-$.$35( "6(3:*(V$%$/345("6(P*'.3:8(X,-.$&(/*&3"4(+4"&,4*#*%3($/(+"".*0('3(3:*(%'3$"%'.(.*1*.8(A:*( V$#%,R4& U$"$$)1,##$5$"& X((%Y,$","8( G,4$%'#*( <UZjG7( V*0$&$%*/( G,++.5(\"#+'%5( G,4$%'#*?( +4"&,4*/( #*0$&$%*/( 6"4( 3:*( +,-.$&( '%0( +4$1'3*( /*&3"48(I*1*43:*.*//7( $3( $/( %"3( 3:*( *@&.,/$1*( /",4&*( "6(#*0$&$%*/( 6"4( 3:*( +,-.$&( /*&3"48(G$%&*( HDDW7( UZjG( :'/( 4*$%34"0,&*0( $%3*4%'3$"%'.( 3*%0*4$%2( +4"&*//( 6"4( +,-.$&(/*&3"4(+4"&,4*#*%38((X,-.$&( /*&3"4( +4"&,4*#*%3( $/( #'$%.5( &"%0,&3*0( 6"4(#*0$&$%*/( "%( 3:*( I'3$"%'.(J//*%3$'.( V*0$&$%*/( [$/3( <JV[?8( Q3( $%&.,0*/( './"( #*0$&$%*/( 6"4( +,-.$&( :*'.3:(+4"24'##*/(/,&:('/(PQjg9Q!G('%0(V'.'4$'7(%"3(.$/3*0(5*3($%(3:*(JV[8(A:*4*('4*(%"(4*2,.'3$"%/(6"4(."&'.(+4*6*4*%&*($%(+,-.$&(/*&3"4(+4"&,4*#*%38((

Medicines financing Q%(HDDM7(3:*(3"3'.(+,-.$&(*@+*%0$3,4*(6"4(#*0$&$%*/(='/(FG`(H7HKR7WMD7(<I'3$"%'.(P*'.3:( 9&&",%3/( HDDM7(V^P?7( 4*+4*/*%3$%2( '4",%0(FG`( K8B( +*4( &'+$3'8( !'3'( "6(#*0$&$%*/($#+"43*0(-5(1".,#*("4(-5(1'.,*(='/('1'$.'-.*8(Q%( G,4$%'#*7( 3:*4*( $/( '( +,-.$&( :*'.3:( $%/,4'%&*( &"#+.*#*%3*0( -5( +4$1'3*($%/,4'%&*(-'/*0("%(3:*(+4$%&$+.*("6(/".$0'4$358(A:*(#*0$&$%*/(64"#(3:*(J//*%3$'.(V*0$&$%*/([$/3('4*(+4"1$0*0($%('(&"_+'5#*%3(-'/$/8(A:*(&$1$.(/*41'%3/('4*(&"1*4*0(-5( 3:*( G3'3*( P*'.3:( Q%/,4'%&*( E",%0'3$"%( <GnE?8( Q6( +4*/&4$+3$"%/( $3*#/( '4*(0$/+*%/*0(-'/*0("%( '%( Gn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

7 Information provided by the National Medicines Quality Control Laboratory in June, 2010. 8 Based on prior benefits and not on their medical condition.

131

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Table 19. Medicines Coverage in insurance schemes and selected public health programmes

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132

G,4$%'#*( :'/( '( %'3$"%'.( #*0$&$%*( +4$&*( #"%$3"4$%2( /5/3*#( 6"4( 4*3'$.( +4$&*/8(I*1*43:*.*//7( 3:*4*( '4*( %"( 4*2,.'3$"%/( #'%0'3$%2( 3:'3( 4*3'$.( #*0$&$%*( +4$&*($%6"4#'3$"%($/(#'0*(+,-.$&.5('&&*//$-.*8((A:*4*('4*(%"("66$&$'.(=4$33*%(2,$0*.$%*/("%(#*0$&$%*(0"%'3$"%/(3:'3(+4"1$0*(4,.*/('%0( 4*2,.'3$"%/( 6"4( 0"%"4/( '%0(+4"1$0*( 2,$0'%&*( 3"( 3:*( +,-.$&7( +4$1'3*( '%0g"4(IZ^(/*&3"4/("%('&&*+3$%2('%0(:'%0.$%2(0"%'3*0(#*0$&$%*/8(

Selection and Rational use of medicines G,4$%'#*k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

133

!""#$%'(%D*2+:#",/%-#,-.#8#5%."%,@#%4-19%7.,#-1,+-#%-#8.#E%1"5%2*--#/A*"5."4%5.:#"/.*"%*>%122#//%,*%:#5.2."#/%155-#//#5(%F1,."%!:#-.21"%C#4.*"G%HIJJ(%

Document Link Dimension of access to medicines

Descentralización de servicios esenciales. Los casos de Brasil, Chile, Colombia, Costa Rica y México en salud, educación, residuos, seguridad y fomento

http://www.eclac.org/publicaciones/xml/8/42298/Descentralizacion_serv_esenciales_ILPES_GIZ.pdf

Health Sector/ Reliable Health System

Regulación y competencia en el mercado de medicamentos: experiencias relevantes para América Latina

http://www.cepal.org/publicaciones/xml/8/41748/2010-057-L977-Serie_121.pdf

Health Sector; Beyond health Sector/ Reliable Health System

Informe de actividades 2006-2008 sobre envejecimiento y desarrollo para el comité especial sobre población y desarrollo del período de sesiones de la cepal

http://www.eclac.org/publicaciones/xml/0/33200/2008-298-SES.32-DDR-2-CELADE-Informeactividades.pdf

Beyond health Sector/ Reliable Health System

Experience Treating The Most Neglected of the Neglected Tropical Diseases

http://www.doctorswithoutborders.org/publications/reports/2010/MSF-NTD-Briefing-Paper.pdf

Public Private Delivery channels/Rational selection and Use; Reliable Health System

development of new drugs for tb chemotherapy Analysis of the current drug pipeline

http://www.doctorswithoutborders.org/news/tuberculosis/tb_xdr_report_full_10-2006.pdf

Health Sector; Beyond health Sector/ Reliable Health System

Gilead’s tenofovir ‘access program’ for developing countries

http://www.doctorswithoutborders.org/news/2006/tenofovir_briefing.pdf

Individual household and Community level; Health Sector/Affordability; Sustainable financing/Reliable Health System

Data Exclusivity & Access to Medicines in Guatemala

http://www.doctorswithoutborders.org/news/2005/access_guatemala_briefingdoc.pdf

Individual household and Community level; Health Sector/Affordability; Sustainable financing

Trading Away Intellectual Property and Access to Medicines in the Free Trade Area of the Americas (FTAA) Agreement

http://www.doctorswithoutborders.org/publications/reports/2003/FTAA_Advocacy.pdf

Health Sector; Beyond health Sector/ Affordability; sustainable financing

A progress Report on TRIPS and Access to Medicines

http://www.doctorswithoutborders.org/publications/reports/2003/cancun_report.pdf

Health Sector; Beyond health Sector/ Affordability; sustainable financing

Reseña del año 2006 http://www.who.int/mediacentre/multimedia/2007/wha60/who_yearinreview_es.pdf

Health Sector; Beyond health Sector/ reliable health System

134


Guidance on Ethics and Equitable Access to HIV Treatment and Care

http://www.who.int/ethics/en/ethics_equity_HIV_e.pdf

Beyond health Sector/ reliable health System

Informe del grupo de trabajo aspectos de los derechos de propiedad intelectual relacionado con el comercio (ADPIC) y acceso a medicamentos

http://www.paho.org/spanish/ad/ths/ev/acceso_intelectual_inf_nicaragua.pdf

Beyond health Sector/ Affordability; sustainable financing

Assessing the impact of exclusion in health on access to medicines

http://new.paho.org/hq/index2.php?option=com_content&do_pdf=1&id=1906

Individual, Household and Community level; Public and private Delivery channels. health Sector/ Rational selection and use; Affordability; Reliable health System

Technical Cooperation in the area of Medicines and Biologicals in the Caribbean


Public and private Delivery channels. health Sector/ Rational selection and use; Reliable health System

Procurement and Supply Management


health Sector/sustainable financing

Public Health perspective on Intellectual Property Rights management


Health Sector; Beyond health Sector/ sustainable financing; reliable health system

The Pharmaceutical Situation in the Caribbean: Factbook on Level I Monitoring: Indicators 2007


Public and private Delivery channels. health Sector/ Rational selection and use; Affordability; Reliable health System

CARIPROSUM-Regional Network of Pharmaceutical Procurement and Supply Management Authorities


Health Sector/sustainable financing; reliable health system

Pricing and Economic Regulation of Medicines


Health Sector; Beyond health Sector/ Affordability sustainable financing; reliable health system

Informe sobre Desarrollo Humano 2003. Los Objetivos de Desarrollo Del Milenio: Un Pacto entre las naciones para eliminar la pobreza

http://hdr.undp.org/en/media/hdr03_sp_complete2.pdf

Beyond Health sector/ sustainable financing; Reliable health system

Assessment of governance and corruption in the pharmaceutical sector: lessons learned from low and middle income countries

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2010/02/18/000334955_20100218041053/Rendered/PDF/530740WP0Pharm10Box345594B01PUBLIC1.pdf

Beyond Health sector/; Reliable health system

135


Intellectual property rights and the TRIPS agreement: An overview of ethical problems and some proposed solutions

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2010/03/02/000158349_20100302132412/Rendered/PDF/WPS5228.pdf

Health Sector; Beyond health Sector/ reliable health system

Improving Access to Medicines for Better Health Outcomes

http://siteresources.worldbank.org/INTHSD/Resources/Presentations/454393-1249391374015/ImprovingAccesstoMedicinesforBetterHealthOutcomesFeb2009.pdf

Health Sector/ Rational selection and use; Affordability; reliable health system

Exploratory study on active pharmaceutical ingredient manufacturing for essential medicines

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2010/02/18/000334955_20100218042121/Rendered/PDF/530750WP0APIEx10Box345594B01PUBLIC1.pdf

Health sector Beyond Health Sector/ Rational selection and use; reliable health system

Improving Access to Medicines in Developing Countries. Application of New Institutional Economics to the Analysis of Manufacturing and Distribution Issues

http://www.femeba.org.ar/fundacion/quienessomos/Novedades/attridge_improving_access.pdf

Health sector Beyond Health Sector/Reliable health system

Access to Medicines and the Innovation Dilemma

http://siteresources.worldbank.org/INTHSD/Resources/Presentations/454393-1249391374015/AccesstoMedicineandtheInnovationDilemmaSept2008.pdf

Health sector Beyond Health Sector/ Sustainable Financing; Reliable health system

Pharmaceuticals: cost containment, pricing, reimbursement

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2006/03/27/000090341_20060327100953/Rendered/PDF/355600HNPBrief17.pdf

Health sector Beyond Health Sector/ Affordability; Sustainable Financing; Reliable health system

Generic drug policies in Latin America

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2005/04/14/000090341_20050414142838/Rendered/PDF/320390HomedesGenericDrugFinal.pdf

Health Sector/ Reliable health System

136


Pharmaceuticals: local manufacturing http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2005/05/03/000090341_20050503161513/Rendered/PDF/321930HNPBrief130Pharmeceuticals.pdf

Health sector; Beyond Health sector/ Rational selection and use; Reliable health system

Community-based health insurance and social protection policy

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2005/06/13/000090341_20050613160831/Rendered/PDF/325450Health0insurance0SP00503.pdf

Individual, household and community level; Health sector/affordability; sustainable financing

Purchasing pharmaceuticals http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2005/02/07/000090341_20050207143123/Rendered/PDF/315000HNP0Purchasing0.pdf

Health sector/ Affordability; sustainable financing

Intellectual Property Rights and Access to Essential Medicines*

http://siteresources.worldbank.org/INTDECINEQ/Resources/IntellectualPropRts.pdf

Health sector Beyond Health Sector/ Affordability; Sustainable Financing;

(

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137

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Name Position Institution Colombia Adriana Mendoza National advisor for

medicines, health technologies, blood, research and bioethics

Pan American Health Organization (PAHO-COL)

Angela Maria Zambrano Production assistant director

National Health Institute

Danik Valera Advisor for health surveillance and public health

National Health Institute

Claudia Vacca Deputy Minister of Health Advisor

Ministry of Social Security

Cruz Elena de Mancaleano

General Secretary National Pharmacists College

Deyanira Duque Ortiz Foment division advisor COLCIENCIAS Francisco Rossi Director INFARMA (NGO) German Holquin General Director Mission for Health

Foundation (additionally, is the coordinator of the Alliance of Civil Society Organization

Janeth Daza Coordinator of drug registration

INVIMA - Drug Regulatory Agency

Lucia Ayala Vice Chairman of the Board

National Pharmacists College COL

Luisa Rubiano Clinical Coordination CIDEIM (Centro Internacional de Entrenamiento e Investigaciones Medicas)

Maria Cristina Baracaldo Coordinator of the medicines and supplies group

Ministry of Social Protection

Martha Cecilia Ramirez National Congress representative

National Congress

Miguel Angel Rendon Executive Director ALIANCOOP Cooperative Alliance Hospitals

Olga Zuluaga Executive Director ACESI Colombian Association of Social Enterprises and Public Hospitals

Ricardo Humerto Rozo Executive Director ASCOFAME (Physician college)

138

Name Position Institution Rosabel Rubiano Coordination of

Surveillance, Inspection and Control

INVIMA (Drug Regulatory Agency)

Dominican Republica Nelson Rodrigues Vice Minister of

Development and Strengthening of Regional Health Services

Ministry of Health

Roberto Peguero Deputy Minister of Finance Ministry of Health Maria Helena Tapia Director Health Surveillance of

Drugs Directora de Vigilancia Sanitaria de Medicamentos

Elena Fernandez Director of the Essential Medicines Program and Executive Director of the Presidential Committee of Pharmaceutical Policies

PROMESE/CAL

Gustavo Rojas Executive Director of the Presidential Commission for AIDS

COPRESIDA

Luiz Ortega Analyst of the Economic Sector

Ministry of Economy

Jaqueline Garnay Officer of Health Systems and Services

Pan American Health Organization PAHO

Guisell Scalon Executive Director INSALUD Pedro Luiz Castellanos Executive Director /

Coordinator of the Health Committee.

NGO Forum (social organizations in general)

Magdalena Rathe Executive Director Fundación Plenitud Pedro Pacheco Chairman Association of

Pharmacists RD El Salvador Eduardo Antonio Espinoza Deputy Minister of Health El Salvador Ministry of

Health (MoH) Violeta Menjivar Escalante Deputy Minister of Health El Salvador Ministry of

Health (MoH) Pedro Rosalío Escobar Castañeda

Chairman Superior Council of Public Health CSSP

María de los Angeles Campos de Murillo

Technical collaborator Ministry of Health of El Salvador (MoH)

Julio Cesar Valdez Dias Executive Secretary Council of Ministers of Health of Central America and Dominican Republic ˙ Rep (COMISCA)

Miguel Antonio Orellana Melendez

Executive Director Salvadoran Association of Health Promotion (ASPS)

Luz Margarita Posada Machuca

Coordinator of the National Health Forum

Salvadoran Communal Promoters Association (APROCSAL)

Claudia Mercedes OrtÌz Aguilar

Researcher National Foundation for Development (BASED)

139

Name Position Institution Margarita Rosa Zaldivar Vice chairman College of Chemical and

Pharmaceutical El Salvador

Julio Enrique Butter Manager College of Chemical and Pharmaceutical El Salvador

Rodolfo Alfredo Canizales Ch!vez

Chairman Medical College of El Salvador

Surinam Celsius Waterberg Minister of Health Ministry of Health Maaltie Sardjoe Director of Regional

Health Services (RGD) RGD (Regional Health Services)

Dr John Hasrat Coordinator of Registration Office of MoH, President of Registration Board/ Lecturer in the Department of

Registration Office / Anton de Kom University - faculty of Medical Sciences

Miriam Naarendorp Pharmacy Policy Coordinator

Ministry of Health

Marisa Valdes Health Systems and Services Advisor

Pan American Health Organization PAHO-SUR

Dr Danso General Physition/ Regional Manager of Brokopondo and Eastern Suriname

Medical Mission (NGO subsidised by government) that gives medical care and medicines for the population in the interior of Suriname

Dr Kloof Family Doctor / Consultant on Continue Education and Cardiovascular diseases

Suriname Diabetes Education Foundation (NGO)

Dr Robbert Bipat Professor at the faculty of Medical Sciences

Anton De Kom University

Dennis Mans Chair of Pharmacology/ faculty of Medical Sciences

Anton De Kom University

Ms Angele Kumbagsila President of Suriname Nurses Association

Suriname Nurses Association

Monique Gonesh Hahn Pharmacist / Chair of the Pharmaceutical Association

Pharmaceutical Association

07$'&#(8/42-6(

Group Name Country Languaje decision maker (MoH)

Fabiola Sulpino Vieira Bra Pt

decision maker (MoH)

Dra Lorena Ruiz ECU Sp

140

Group Name Country Languaje decision maker (MoH)

V'4,;'(\4$/'%3*( X*4,( G+(

Indústria Brenda Colatrella USA En Int Agency (PAHO) Gustavo Vargas BLZ J%(Int Agency (PAHO) b"/*([,$/(0*(\'/34"(<^XG?( U4'( G+(Int Agency (PAHO) Victor Arauz ECU Sp Int Agency (PAHO) Juana Rodríguez GUA Sp Int Agency (PAHO) I*..5(V'4$%( FG9( G+(ONG Oscar Lanza Bolívia Sp ONG Célia Chaves Bra Pt ONG Jorge Beloqui Bra Pt ONG Marcela Vieira Bra Pt ONG Luis Guillermo Restrepo COL Sp ONG Sandra Guzman COL Sp ONG Sr. Juan Cuvi ECU Sp ONG Javier Llamoza Peru Sp Researcher Maria Gabriela Paraje ARG Sp Researcher Perla M. De Buschiazzo ARG Sp Researcher 9%04*'(!p#'/"(U*43".0$( U4'( X3(Researcher \.',0$'(Z'4&$'(G*4+'(^/"4$"(0*(

\'/34"(U4'( X3(

Researcher Dayani Galato Bra Pt Researcher G$.1'%'(I'$4([*$3*( U4'( X3(Researcher j*4'(X'%$>( U4'( X3(Researcher j*4'(X*+*( U4'( X3(Researcher Luis Bernardo Villalobos, COR Sp Researcher Dr. Ramiro López ECU Sp Researcher José Terán ECU Sp Researcher Milton Gross ECU Sp Researcher j*4"%$O'(T$43>( VJq( G+(Researcher Dennis Ross-Degnan USA En

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