Date Published: March 27, 2007
Publisher: Public Library of Science
Author(s): Suzanne Hill
Abstract: Hill discusses the implications of a new survey on drug prices and availability in Malaysia.
Partial Text: Pharmaceuticals make a major to contribution to health. However, as noted by Ess et al., in Europe over the last 20 years, expenditure on pharmaceuticals has grown faster than the gross national product, and Wagner and McCarthy described the problem in low-income countries where “the vast majority are unwilling to pay for effective drugs simply because they are unable to pay” [1,2]. Up until the 1990s, studies examining drug prices were few and far between, and in developing countries were nonexistent. Measuring comparative prices of medicines was seen as complex, and rightly so—many methodological challenges face such studies (Box 1) [3,4].
In a new study published in PLoS Medicine, Babar et al.  report the results of a survey of drug prices and availability in Malaysia. This is one of many surveys that have been carried out, using a standard methodology for pricing surveys that has been developed by HAI in collaboration with the World Health Organisation since 1998. This standard method encourages systematic data collection, reporting, and analysis of prices of a “basket of medicines” to enable comparison within and across countries with the aim of informing pharmaceutical policy development. The method has been field tested, validated, and used in nearly 50 surveys in different countries, the results of which are all publicly available on the HAI Web site (http://www.haiweb.org/medicineprices). Having an internationally agreed method for surveys is an important step in improving the acceptance of the results; medicine prices are always a politically sensitive subject.
The limitations of this study are those of most one-off cross-sectional surveys: How representative are the results for the pharmacies and facilities sampled overall? In a country of 20 million people with hundreds of hospitals and pharmacies, is it sufficient to draw general/national conclusions from a sample of 20 public hospitals, 32 private sector pharmacies, and 20 dispensing doctors? This is clearly an important limitation, and ideally repeating the survey using a larger sample, or with repeated measures over time, would provide a more robust picture. However, in the absence of automated systems for recording the dispensing, prescribing and cost of medicines, data collection of medicine prices is labour intensive, and it is therefore necessary to balance the ideal with the possible. Having some initial results provides a starting point for untangling the problem of high drug prices in Malaysia.
The challenge now for the authors, and also for the HAI project overall, is to answer the “so-what” question. Prices of medicines in Malaysia may be high, but are these prices really affecting access to medicines (hard to measure) or health outcomes (even harder to measure)? Should there be wholesale policy change from a “free market” to control of medicine prices? If so, should all points in the supply chain be regulated—that is, from manufacturer to dispensing—or just some? If so, how? What policies are possible, and what impact would they have? South Africa has taken the step of introducing controls on pharmacist dispensing fees , but could have also opted to regulate other parts of the supply chain—what would be the impact? In a low- or middle-income country, how do you decide on the tradeoff between regulating prices and supporting the local pharmaceutical industry, which might be your main source of cheap(er), but good quality products? A systematic review by Aaserud et al.  published last year summarized studies of some pricing policies that are widely used in developed countries, and concluded that there is very little information to assess benefits and harms of particular policy options, in terms of impact on prices, affordability, or health comes. But this review did not find any studies from developing countries that could inform decision-making, and most of the policies were variations on reference pricing approaches.
As noted on the HAI Web site, “Reliable data is the first step to exploring policy options and taking action.” There are many question to answer. For each country that has done the survey, like the Malaysian study, the first question is whether this a true picture of the situation and whether it remains so over time. The study samples only a limited number of medicines—what about other important groups (such as children and the terminally ill)? But most importantly, once the data are collected, what are the policy options for a country and what impact will they have? If there is to be any chance of evidence informing policy decisions in this challenging field, then the transparent process encouraged and developed by HAI must continue—prices cannot be the subject of closed-door negotiations and the factors that contribute to pricing should be detailed so that those who pay know what they are getting for their money.