Upload
dylan-jackson
View
214
Download
1
Tags:
Embed Size (px)
Citation preview
Update on the Affordable Medicines Facility-malaria (AMFm) / Private Sector Co-payment Mechanism for ACTs
Interagency Pharmaceutical Coordination Group Meeting 18-19 June 2015
Dr. Melisse MurraySpecialist, Sourcing Department
Key events leading to the start of Phase 1
2004 IOM releases report Saving Lives, Buying Time - Global-level subsidy for ACTs an urgent “public good” to address increasing ineffectiveness of widely available treatment, risk posed by oral AMTs and the high cost of ACTs
2006 Roll Back Malaria (RBM) Partnership fosters multi-institutional process
2007 AMFm Technical Design approved by RBM Board - Included the addition of “supporting interventions” (SIs) to promote the appropriate use of
ACTs
Hosting and management by the Global Fund- 2008 Global Fund Board requests the Secretariat to begin operations - 2009 select countries invited to submit applications, Technical Review Panel recommendations, Global Fund Board approvals- By mid 2010, Global Fund grant amendment processes completed for each pilot to
permit initiation of country-level operationsIOM = Institute of Medicine ACT: Artemisinin-based combination therapy AMT = artemisinin mono-therapy
Purpose:
Widely availability of quality-assured ACTs Sharply retail prices of quality-assured ACTs use of quality-assured ACTs, including by vulnerable groups Displace oral artemisinin monotherapies Displace use of ineffective medicines
AMFm comprised three elements:
1) Negotiations with ACT manufacturers price of ACTs and offer public sector prices to private sector buyers
2) Buyer subsidy (co-payments) at top of global supply chain price to importers; use pre-existing supply chains
3) “Supporting interventions” to ensure effective ACT scale-up Including communications campaigns, private sector training, etc.
Phase 1 was a “Test of Concept”
ZANZIBAR
AMFm Phase 1 Private Sector Co-payment Mechanism
4
Mid 2010 to end 2012: AMFm Phase 1 implementation
>Mid 2010 to end 2012 in nine pilots in eight countries: Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania, Uganda and Zanzibar
>Four donors funded co-payments (US$ 333 million):
>Global Fund grants funded supporting interventions (IEC/BCC, private sector training, etc.)
>290 million co-paid treatment doses delivered by end 2012, mostly A/L
November 2012 Global Fund Board Decision*>Based on evidence from AMFm Phase 1 Independent Evaluation*, following a transition period, and building on lessons
learned, grantees permitted to use grant funding for co-payments and supporting interventions
>Going forward: private sector only; each country to determine subsidy level and demand-shaping levers*Board Decision and full AMFm Phase 1 Independent Evaluation Report available in public domain.
0
50
100
150
Co-p
aid
ACT
s D
eliv
ered
(t
reat
men
t co
urse
s,
in
mill
ions
)
012345
85% A/L
11% ASAQ FDC
0% DHA-PPQ
3% ASAQ Co-b
5
Questions asked by IPC:
• How have changes since the end of AMFm Phase 1 impacted the availability of co-paid ACTs in private sector outlets in these countries?
• How have changes since the end of AMFm Phase 1 impacted the price of co-paid ACTs available in private sector outlets in these countries?
6
Summary of key changes since the end of AMFm Phase 1
Key changeAMFm Phase 1
(mid-2010 to end-2012) 2013 Transition2014 Transition/
IntegrationParticipating countries
9 pilots in 8 countries 6 countries 5 countries (6th to resume in 2015)
Source of co-payment funding
plus grant funds in 2 countries
Co-payment financing
Resources mobilized for co-payments across all
pilots for the periodCountry-specific financial amounts for co-payments
Subsidy level and demand-shaping levers
Set by Secretariat and applied across all pilots
simultaneously
Set by each country and applied on country-specific basis, evolving over time
Timing of order approvals
On demand then monthly Aug 2011 to Dec 2012
Bi-monthly Quarterly
Price negotiations with ACT suppliers
Maximum price approachCompetitive tender resulting in supplier- and product-specific
prices (~ 30% reduction)
7
Annual quantities of co-paid ACTs delivered to private sector buyers in six participating countries since the end of AMFm Phase 1 (end 2012)
have decreased or increased, depending on the country
Annual quantities of co-paid ACT treatment doses delivered to private sector buyers 2010 to 2014, as reported to the Global Fund by ACT suppliers
Ghana Kenya Tanzania Uganda0
5
10
15
20
25
Peak in 2012
Nigeria0
10
20
30
40
50
60
70
Madagascar0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
2010
2011
2012
2013
2014
Co
-pa
id t
rea
tme
nt
do
ses
de
live
red
to
p
riva
te s
ect
or
bu
yers
, in
mill
ion
s
AM
Fm
Ph
as
e
1
AMFm Phase 1 Peak in 2013
Peak in 2011
Trends in Availability and Price of Co-paid ACTs • No formal post-AMFm Phase 1 evaluation has been undertaken.
• Trend data is available from surveys implemented by Health Action International*- Commissioned by Global Fund during AMFm Phase 1 and beyond in select countries.- Not intended to substitute in scope or depth for the Independent Evaluation, which reported
on urban and rural availability, price and market share of all categories of antimalarials, and more.- Intended to provide visibility on availability and price of co-paid ACTs to facilitate
in-country discussions by implementers, technical partners and the Global Fund, with a view of informing adjustments as and when appropriate.
- Four rounds of surveys conducted between Jun and Nov 2011, four rounds between Jan and Sept 2012, two rounds in 2013, plus four rounds in DFID-supported countries in 2014, using the same methodological approach.
• 30 formal and 30 informal outlets were visited per country, per round.• Formal outlets defined as registered retail pharmacies; • Informal outlets defined as unregulated, unlicensed outlets.
• Availability of products bearing the ACTm logo and their prices are recorded, along with some additional information (e.g., price of originator brand and lowest priced generic).
* For additional detail on the use (and limitations) of WHO / HAI methodology to analyze medicines availability, see www.haiweb.org/medicineprices.
9
Annual trends in availability of co-paid ACTs in formal outlets appear to follow trends in quantities of co-paid ACTs delivered.
20
10
20
11
20
12
20
13
20
14
20
10
20
11
20
12
20
13
20
14
20
10
20
11
20
12
20
13
20
14
20
10
20
11
20
12
20
13
20
14
0
5
10
15
20
25
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ghana Kenya Tanzania Uganda
20
10
20
11
20
12
20
13
20
14
0
10
20
30
40
50
60
70
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nigeria Madagascar
Co-
paid
trea
tmen
t dos
es d
eliv
ered
to p
rivat
e se
ctor
buy
ers,
in m
illio
ns
Average annual availability of any co-paid ACTs in formal outlets, as reported by HAI, 2011-2014, and annual quantities of co-paid ACTs delivered to private sector buyers, as reported to the Global Fund by ACT suppliers, 2010-2014
20
10
20
11
20
12
20
13
20
14
0
0.2
0.4
0.6
0.8
1
1.2
1.4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
10
20
10
20
11
20
12
20
13
20
14
20
10
20
11
20
12
20
13
20
14
20
10
20
11
20
12
20
13
20
14
20
10
20
11
20
12
20
13
20
14
0
5
10
15
20
25
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ghana Kenya Tanzania Uganda
20
10
20
11
20
12
20
13
20
14
0
10
20
30
40
50
60
70
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nigeria Madagascar
Co-
paid
trea
tmen
t dos
es d
eliv
ered
to p
rivat
e se
ctor
buy
ers,
in m
illio
nsAnnual trends in availability of co-paid ACTs in informal outlets appear to show greater variation/more sensitivity over time than measures in formal outlets in some countries.
Average annual availability of any co-paid ACTs in formal and informal outlets, as reported by HAI, 2011-2014, and annual quantities of co-paid ACTs delivered to private sector buyers, as reported to the Global Fund by ACT suppliers, 2010-2014
20
10
20
11
20
12
20
13
20
14
0
0.2
0.4
0.6
0.8
1
1.2
1.4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
11
Countries achieved different prices at the end of 2011 as documented in the AMFm Phase 1 Independent Evaluation, with different paces and
scale of implementation of supporting interventions, particularly of IEC/BCC
Ghana Kenya Madagascar Niger Nigeria Tanzania mainland
Uganda Zanzibar0.00
1.00
2.00
3.00
4.00
5.00
6.00
2.74
0 0 0 0 0 0 0
0.94
0 0 0 0 0 0 0
3.42
2.63
0.14
2.47
4.47
5.28
2.79
5.99
1.130.58 0.60
1.191.48
0.94
1.96
1.17
Public health sector (Baseline) Public health sector (Endline) Private for-profit sector (Baseline)Private for-profit sector (Endline)
Med
ian
cost
to
patie
nts
of o
ne A
ETD
of
QA
ACT
s in
pub
lic a
nd p
riva
te fo
r-pr
ofit
outl
ets
(US
dolla
r eq
uiva
lent
)
12
Since the end of AMFm Phase 1, retail prices of co-paid A/L 6x4 have generally increased, possibly linked to either decreases in deliveries of co-paid ACTs or a reduction in subsidy level (or both), with the
exception of Madagascar. Further, it should be noted that nearly every country has scaled down communications campaigns regarding the subsidy program following a peak during AMFm Phase 1.
CountryOutlet Type
Number of unique price observations
Median Retail Price of co-paid A/L 6x4 AMFm
Phase 1 period
Number of unique price observations
Median Retail Price of co-paid
A/L 6x42013-2014
Per-cent-age
change in price
Key observations
GhanaFormal 359 $ 0.93 54 $1.20 28% Peak deliveries late 2011, further
decline in 2013 linked to 2013 Transition envelopeInformal 103 $ 0.96 10 $1.50 56%
KenyaFormal 371 $ 0.52 227 $1.17 125% Peak deliveries in Q3 2012; subsidy
level reduced to 70% in 2013 Informal 207 $ 0.53 109 $1.15 117%
Nigeria Formal 450 $ 1.44 283 $2.01 40% Peak deliveries Q3 2013; subsidy level
reduced to 85% in 2013Informal 370 $ 1.50 260 $1.81 20%
TanzaniaFormal 285 $ 0.63 63 $0.92 47% Peak deliveries in Q2 2012; subsidy
level reduced to 80% in 2013Informal 211 $ 0.70 50 $0.92 33%
MadagascarFormal 73 $ 0.51 33 $0.46 -11% Peak deliveries in 2013, when
implementation was on hold.Informal 29 $ 0.57 8 $0.69 22%
Uganda Formal 440 $ 1.24 227 $1.81 46% Peak deliveries in early 2014, just as
subsidy level is reduced to 50%Informal 191 $ 1.81 128 $1.95 8%
* Data as reported by HAI, per methods described in previous slides. Key observations noted by Global Fund.
13
Three examples of country-specific variation regarding changes in deliveries of co-paid ACTs, prices of co-paid A/L 6x4 and changes in subsidy levels over time
2011 2012 20130
5
10
15
20
25
$-
$0.20
$0.40
$0.60
$0.80
$1.00
$1.20
$1.40
$1.60
2011 2012 2013 20140
5
10
15
20
25
$-
$0.20
$0.40
$0.60
$0.80
$1.00
$1.20
$1.40
$1.60
2011 2012 2013 20140
10
20
30
40
50
60
70
$-
$0.50
$1.00
$1.50
$2.00
$2.50
$3.00
Co
-pa
id t
rea
tme
nt
do
ses
de
live
red
to
p
riva
te s
ect
or
bu
yers
, in
mill
ion
s
Hig
he
st,
low
est
an
d w
eig
hte
d a
vera
ge
me
dia
n p
rice
s o
f c
o-p
aid
A/L
6x4
, f
orm
al o
utle
ts,
rep
ort
ed
by
HA
I
Introduction of subsidy reduction
Introduction of subsidy reduction
Ghana Kenya Nigeria
14
HAI data from February 2015 reports prices of subsidized ACTs below those of unsubsidized originator brands and
lowest priced generics.Median price trends of A/L 20/120 mg (6x4): co-paid (AMFm) versus
unsubsidized originator brand and lowest price generic, February 2015
15
Key conclusions
• Several changes have been implemented since the end of AMFm Phase 1 in countries that have chosen to implement the Private Sector Co-payment Mechanism.
• Data available for the six AMFm Phase 1 countries implementing the Private Sector Co-payment Mechanism indicate variations across countries in the annual supply of co-paid ACTs delivered to private sector buyers each year, availability and price of co-paid A/L 6x4 in retail outlets.
• These need to be interpreted in light of implementation changes that have occurred with the private sector co-payment mechanism, including reductions in subsidy levels in some countries.
From RBM:
• Key Learnings from AMFm Phase 1
From the Global Fund:
• AMFm Phase 1 Independent Evaluation Report
• Information Note on the Private Sector Co-payment Mechanism
• Operational Policy Note
• HAI Price Tracking Survey Reports
Additional Resources on AMFm Phase 1 and the Private Sector Co-payment Mechanism
18
Data for slide 12: HAI survey data2011: 4 rounds; 2012: 4 rounds; 2013: 3 rounds; 2014: 4 rounds
2011* 2012* 2013** 2014*
NMedian Price N
Median Price N
Median Price N
Median Price
Ghana Formal 168 $ 0.97 191 $0.90 54 $ 1.20 Informal 38 $ 0.99 65 $0.94 10 $ 1.50 Kenya Formal 229 $ 0.43 142 $0.67 67 $ 1.17 160 $1.18 Informal 118 $ 0.43 89 $0.67 34 $ 1.17 75 $1.14 Tanzania Formal 153 $ 0.62 132 $0.64 63 $ 0.92 Informal 109 $ 0.75 102 $0.64 50 $ 0.92 Uganda Formal 204 $ 1.13 236 $1.33 79 $ 1.95 148 $1.73 Informal 81 $ 1.74 110 $1.86 40 $ 1.95 88 $1.95 Nigeria Formal 213 $ 1.30 237 $1.57 111 $ 2.04 172 $2.00 Informal 167 $ 1.40 203 $1.59 91 $ 1.73 169 $1.85 Madagascar Formal 23 $ 0.60 50 $0.48 33 $ 0.46 Informal 9 $ 0.54 20 $0.58 8 $ 0.69
19
Trends in availability of co-paid ACTs in private sector outlets late 2011 to 2014, as reported by HAI International
Ghana Kenya Madagascar Nigeria Tanzania Uganda0
20406080
100
Ghana Kenya Madagascar Nigeria Tanzania Uganda0
20406080
100
Aug-11 Oct-11 Nov-11 Jan-12 Apr-12 Oct-12 Apr-13 Aug-13 Jan-14 Apr-14 Aug-14 Oct-14
Per
cen
tag
e o
f fa
cil
itie
s h
avin
g
any
AC
Tm
AC
T a
vail
ab
le
Fo
rma
l O
utl
ets
Info
rma
l O
utl
ets
• Availability of co-paid ACTs in informal outlets appears to be more sensitive than that in formal outlets.
• Availability as reported by HAI appears to track with deliveries of co-paid ACTs to each country as reported to the Global Fund by ACT suppliers.
20
Price trends of co-paid ACTs• A February 2015 round of data collection by HAI International revealed a decrease and
increase in formal and informal outlets in Kenya, decreases in Nigeria and Uganda. Data was not collected during 2014 in Ghana and Tanzania.
• It should be noted that subsidy levels decreased in several countries from AMFm Phase 1 levels of ~95% (to 70% in Kenya, 85% in Nigeria and 50%/70% in Uganda).
Price trends of A/L (20/120 mg) (6x4) in private sector outlets