Health Care Equity Issues in Middle East
Ibrahim Al-Abbadi Bpharm, MBA, PhD, 2007 ISPOR International Fellowship Award recipient and Assistant Dean for Training Affairs, University of Jordan, Amman, Jordan.
The following was presented during the Second Plenary Session, “Improving Equity of Access to Pharmaceutical Therapies in Europe, Middle East & Africa,“ at the ISPR 11th Annual European Congress, November 10, 2008, Athens, Greece)
This article will discuss Health Care Equity Issues in Middle East and use Jordan as its model. It will introduce the region, discuss both health related issues, general health priorities in the Middle East region, and describe Jordan’s organizational activities to improving the equity for essential medicines. Jordan was selected as the model in the Middle-East area for this article, as it represents most of the countries in that region with a lower middle income country, but as having the human resources to bring Jordan to a developed country status.
The Middle East is divided into two main regions: Western Asia and North Africa. In Western Asia (on the Arabian Peninsula) are the Gulf Council countries of Saudi Arabia, Kuwait, Qatar, Bahrain, United Arab Emirates, and Oman. These are considered middle-income countries due to the influence of the oil in the region. Yemen and Iraq can be included, despite the fact that there income is lower than these others countries. In the Persian Plateau, we have Iran, Afghanistan, and Pakistan. In the Levant area, there is Jordan (as our model), Lebanon, Syria, and Palestine, and then the North African countries of Algeria, Egypt, Libya, Morocco, and Tunisia. Regarding the pharmaceutical market, Middle East is not that big area, Saudi Arabia, Algeria, and Egypt are considered large markets, each with a private-market size of more than a half-billion dollars a year. Without equitable access to essential medicines for a variety of diseases, the fundamental right for health care cannot be fulfilled. Countries which have a critical shortage of health services in terms of personnel (doctors, nurses) in the Middle East area are Iraq and Morocco. There is then the unique situation in Palestine, as the military occupation is a basic fact of life for all Palestinians, and shows how poverty and gender inequity has resulted in a serious deterioration in health equities and health status. There is an extreme lack of health care and the maintenance of social welfare in all of these areas.
People in the Middle East are suffering from an increasing incidence of disability and death due to road accidents. Also, the climate changes in the region alter the calendar year from four seasons to two, and air pollution and contamination of drinking water is still prevalent. There is a lack of research within health authorities in Jordan; there are many ideas on what to research, but the main problem is lack of information. The bodies gathering national statistics are under- developed, making data, if not lacking altogether, relatively unreliable. There is a lack of resources providing comprehensive health care service; the lack of health economics and cost effectiveness methods is also a problem. For example, in Jordan, there are only three active health economists or pharmacoeconomists. There is a shift in the region, especially in Jordan, from communicable diseases, to non-communicable diseases, perhaps due to satisfactory education. Communicable diseases were partly controlled but continued to be a problem in crisis countries. There is a high incidence of non-communicable diseases such as cancer and diabetes, and a high prevalence of cardiovascular diseases and problems of mental health, possibly as a result of economic burden, social, and geopolitical pressures. There is widespread distribution of disease risk factors and related bad habits such as smoking, obesity, and lack of physical exercise. Tobacco use is a major cause of mortality, morbidity, and poverty, but while the majority of poor people have little control over most of the causes of their poverty and ill health, tobacco use is the one notable exception. Improving the leadership and governments of the health authorities, i.e., the Ministry of Health is a priority in the Middle East. There is also a need for fair and accurate financing of the health system. We need to develop balanced human resources for health, increase the availability of access and use of information, identify cost effective interventions that target the major health problems (i.e. prioritization), and develop health promotion programs and support community based initiatives.
In terms of general pharmaceutical issues, we need to define what is meant by ‘essential medicines’, as those that satisfy the health care needs are a priority to the population. Essential medicines are more costly in our area and less available. For example, in the public sector, generic medicines are only available in 35% of the facilities, while the average prices of medicines is 2.5 double in relation to the international reference prices. Ban Ki-moon (General Secretary of the United Nations) commented that it is not enough to have effective and safe medicines if they are not affordable and available to those who need them. Generally, both branded, as well as generic products were found to be highly priced. The private market or the private sector return prices were also higher, generally for both generic and brands. For example, in a WHO study two years ago, it was concluded that medicine prices in Jordan private sector are almost 17-fold compared to those of the international reference prices of branded products, and for generics, it is 10 times the international reference price. Most of the treatment courses for common, acute, and chronic diseases were unaffordable. Some countries were still taxing medicines in different forms and the markups are very high for the wholesaler and retailer. Summarizing, there is a lot to be done!Basic health indicators for Jordan are improving, especially in the last 15 years. The infant mortality rate and the under-five mortality rates are very small, as well as the maternal mortality rate. Full immunization coverage in a 12-month period is almost 90%. Almost all women seek at least one pre-natal visit and births attended by skilled personnel are also 100%. Access to safe drinking water is assured for almost 98% of the population. Access to improved sanitation is just 60% and needs to be addressed. Children under five years of age who are underweight are just 4%, which is very encouraging.
What are the social health care challenges in Jordan? There is a high rate of unemployment, growing social inequity, and a high rate of immigration. Jordan had three major immigration movements in the last century: 1948 from Palestine, 1967 from Palestine, and 1991 from the Gulf region. The growing population requires an investment in education and health services. In addition, the elderly population is growing and has increasing demands for health care. Scarcity of water resources affects domestic water supplies, which are essential for health maintenance. Just recently, it was reported that Jordan is the fourth-leading, poverty-level country in water availability. On the other hand, Jordan has an effective health care system in which it is considered as one of the most modern health care infrastructures in the Middle East region. The main objective of Jordan’s health care strategy is to improve and to provide access to health for all Jordanians by 2012. The Ministry of Health is responsible for public health, quality standard setting, and medical education and training. Beyond setting standards and approving charge schedules, there is little control over the private market. The health care system in Jordan is divided into two subsystems: a public health care system and private health care system. About 50% of the outpatient visits of Jordan take place at the facilities of the Ministry of Health. Forty percent take place in the private facilities, while the remaining 10% are divided between royal medical services and university hospitals. Approximately 40% of health expenditure is out of pocket. On average, Jordanians pay around $47 per annum on outpatient care, out of which 70% is for pharmaceuticals.
With the existence of a two-tiered health system, inequities are evident in the distribution of health care expenditures. Sixty percent of health expenditure is in the private sector which provides only 20% of health services and at the same time, 80% of the services are provided by the public sector which accounts for only 40% of the expenditure. Women have higher out of pocket expenditures on health and use the health services more frequently than men. Regarding health insurance coverage in Jordan the Minister of Health recently announced that Jordan reaches 85% coverage of the population. The Ministry of Health insures approximately 20% of the population and approximately 33% are covered by Royal Medical Services (the military personnel and their families). Palestinian refugees hosted in Jordan and their families, approximately 20%, are also healthily insured by United Nations, and the privately insured people in Jordan accounts for 8%. This seems, in total, that 80% are covered by insurance in Jordan, but actually only 25% of the population has no health insurance, this is due to double insurance i.e. some people are insured by Ministry of Health and Royal Medical Services at the same time.
Jordan has also a problem with uninsured citizens adding to inequalities in access to health care. These Jordanians are between 15 and 45 years of age, low educated, and live in urban areas. They have less-than-average access to outpatient care and have more than average out-of-pocket expenditure. Jordan does, however, has also a ‘rescue’ possibility, in that the Jordanian Royal Court might by application allow that in-need patients get admission to public hospitals with full reimbursement.
There are wide-spread cooperation and coordination efforts with international organizations, such as the WHO, Health Action International, the United Nations and the World Bank. There is also a desire to ask more European agencies to assist Jordan to improve its health system as model in the region. International activities by these organizations resulted in describing the status quo of the health system in the Middle East. One result was there are unaffordable medicine prices which are a major barrier to access medicine, especially for the poor and sick. For example, a full course of antibiotics to cure common pneumonia may cost a month’s salary, and one year of HIV treatment would consume 30 years of income. One-third of the population of the world does not have reliable access to medicines. The price of medicine is a public health issue and should not be left to commercial considerations of suppliers and manufactures alone. Spending on medicines in low income countries is far lower per capita than in high income countries. Access to medicines, nevertheless, continues to be the biggest challenge. For example the mean percentage for total health expenditure on medicines in lower middle income countries such as Egypt, Jordan, and Morocco, is approximately 35%, which is very high compared to approximately 12% in the rest of the world.
There are many suggestions that can be implemented: there needs to be good governance, which is a key factor to achieving equitable health care delivery. In the pharmaceutical sector, ensuring appropriate processes for the development, implementation, and monitoring of medicine policies with clear objectives to ensure equitable access to essential medicines. There needs to be transparency and accountability in medicine procurement and pricing, appropriate structure and effective functioning of national regulatory authorities; adequate and equitable financing, trained human resources, and reliable and an efficient information system.
There was a framework structured by international organizations to guide action to access to essential medicines (rational selection, affordable prices, sustainable financing, reliable health, and supply systems). National treatment guidelines based on the best available evidence regarding efficacy, safety, quality, and cost effectiveness need to be developed. There also needs to be a developmental list of essential medicines, based on these national treatment guidelines. In addition, this list needs to be used for procurement and reimbursement. In Jordan, we are beginning to work on a rational selection framework resulting in the selection of essential medicines with the help of the government in the United Kingdom through the Medicines Transparency Alliance (MeTA) project.
We need to allow price competition, promote bulk procurement, implement generic policies and encourage local production of quality medicines. In Jordan, there are good local manufacturers; more than 20 local manufacturers in a small country like Jordan which were founded in the last five decades (the first started in 1962), some of them already selling to countries in Europe and the US.
One further issue will be the need to reduce out of pocket spending, especially in the poor, and expand health insurance. Jordan in the coming years may reach full health insurance coverage, but needs to target external funding of specific diseases with high public health impact to ultimately integrate medicines and health sector development and create efficient supply delivery to reduce markups. In addition, there is a need to assure the quality of medicines (which is expected to be regulated).