Equity and Access to Health Care in Russia

Professor Pavel Vorobyev, MD, PhD

Oleg Borisenko, MDRussian Society for Pharmacoeconomics and

Outcomes Research

Agenda

• Equity and access to medical care in Russia

• Equity and access to common medicines

• Equity and access to high-cost medicines

• Reforms in health care: how can they affect the access to drugs?

Auto-RunAuto-Run Moscow - BaikalMoscow - Baikal24.07-16.08 200824.07-16.08 2008

16 16 000 kilometers by car000 kilometers by carlooking for equity in

health care

On the side – emblems of RSPOR и ISPOR

From From Europe Europe to Asia to Asia

and and backback

Rare minutes of rest -on the salt lake Tuz

General problems of access to medical care (1)

Difficulties of physical access

 (big distances, traffic on roads in big cities, concentration of medical technologies in several administrative “centers”, absence of primary care physicians and paramedics)

General problems of access to medical care (2)

The needs of population for health care are unknown : the need for cardio surgery, oncology, hematology, hemodialysis, transplantation, orthopedics, orphan drugs etc., is in several times (25-30) higher than actually performed workload 

General problems of access to medical care (3)

• The low level of health care financing – 11-15 billion dollars on drugs for 145 million people

General problems of access to medical care (4)

• The availability of medical care to vulnerable citizens is not discussed: prisoners, military personnel, nonresidents, poor citizens, homeless

Russian health care market (expert opinion)

• Government financing (budgets, obligatory insurance) – no less than 25 bill. EUROS

• Patient expenditures (data of Ministry of Health – except “grey” schemes and private sector) is about 10 bill. EUROS

• Experts: patients spend in fact 1,2-1,5 times more money than government, it is about 30-35 bill. EUROS

• TOTAL: health care services and pharmaceuticals market in Russia is about 55-60 bill. EUROS

Access to common medicines (1)Access to common medicines (1)

• Less than 10-15% of population has an access to reimbursement 

• Financing lists include 20% of drugs with proven ineffectiveness and with unproven effectiveness; costs are the greatest in the reimbursement system

• Many drugs, which are included in the reimbursement system, are not available in hospitals

• Pharmaceutical market of BAA is growing – about 1 billion $ in 2008 биодобавки позиционируются как лекарства и вытесняют их с рынка

• Self-treatment is widespread (including antibiotics, hormones, etc.) 

• In 2007 people spent 7.2 billion U.S. dollars on drugs

Access to common medicines (2)Access to common medicines (2)

• Since 1990-s – each region has been spending money on drugs for “special categories of people”, programs vary significantly from region to region

• Since 2000 – one List of Drug on the basis of List, developed by the Formulary Committee

• Since 2004 – new federal drug reimbursement program (DLO) – divides population covered with reimbursement into 2 groups.

• The first group is financed from state budget, the second one – from regional budgets. Since 2005 “federal” group may “take money instead of drugs”, it has resulted in a 70%-decrease of program participants number – about 4% of Russian population

The program for socially significant diseases – diabetes mellitus,

tuberculosis, HIV-AIDS , hypertension, mental diseases,

oncology. Basically money are spent on equipment, educational programs.

Money on drugs - from regional budgets and other sources.

Access to expensive, rare used (orphan)

medicines

Access to rare used (orphan) medicines

• Since 2008 a new program - «7 rare expensive diseases» - was extracted from DLO program and received extra money

• Since 2008 patients with hemophilia, cystic fibrosis, hypophysial nanism, Gauche disease, myeloleukemia and other hemoblastosis, disseminated sclerosis, condition after transplantation have more access to treatment

• 2 bill EUROS for 2 years• New program covers 17 the most expensive drugs:

Somatropin, Glatiramer acetate, Interferon beta-1a, Interferon beta-1b, Bortezomib, Imatinib, Rituximab, Fludarabine, Imiglucerase, Dornase alfa, Mycophenolic acid, Mycophenolate mofetil, Tacrolimus, Ciclosporin, Antihemophilic factor VIII, Octocog alfa, Antihemophilic factor IX, Eptacog alfa (activated)

• Program will be completed in 2009, perspective is unknown

The number of patients with expensive diseases to to 01.01.2008, 01.01.2008, applications were submitted and drugs were

purchased for them

At the end of 2008, the program involves about 49 000 patients 

Factor VIII concentrate supply in Factor VIII concentrate supply in Russia, IU per capitaRussia, IU per capita

RUSSIAN HEMOPHILIA SOCIETYNational member organization of the World Federation of Hemophilia

0,054 0,065 0,0390,212 0,219

0,788

1,63 1,6

3,2

0,0950,2050,1440,0630

0,5

1

1,5

2

2,5

3

3,5

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

HIV-AIDS (1)

• By the end of 2006, the Russian Federation had cumulatively registered 373 259 HIV cases and 3507 AIDS cases. These numbers exclude 8083 HIV cases reported among foreigners as well as 16 929 unconfirmed cases among children born to HIV infected mothers.

• The cumulative number of registered deaths among people living with HIV was 19 269.

http://www.euro.who.int/aids/ctryinfo/overview/20060118_36

http://demoscope.ru/weekly/2008/0337/reprod01.php

HIV-AIDS (2)

• In 2006, a total of 135 340 HIV/AIDS patients received medical care, including medical follow up and treatment related to concomitant disease.

• By December 2006, a total of 14 681 PLHIV had initiated HAART of which 1430 dropped out of treatment in 2006.

• By December 2007, a total of 31 094 people had initiated HAART in the Russian Federation.

http://www.euro.who.int/aids/ctryinfo/overview/20060118_36

http://demoscope.ru/weekly/2008/0337/reprod01.php

HIV-AIDS (3)

• In 2007 the average number of 13-20% registered patients in Russia  was adopted as an indicator of the adequacy of coverage by ARV therapy.

• Currently feature of HIV infection in Russia is the rapid increase in the number of patients, who need antiretroviral (ARV) therapy, because the largest number of HIV cases was registered  in 1999-2001.

http://demoscope.ru/weekly/2008/0337/reprod01.php

Reimbursement drug list for HIV-AIDS 2008

• Abacavir (also in combination), • Atazanavir, • Darunavir, • Didanozin, • Indinavir, • Zidovudin (also in combination), • Lamivudin (also in combination), • Lopinavir/ ritonavir, • Nevirapin,

• Ritonavir (also in combination), • Sacvinavir, • Stavudin, • Telbivudin, • Phosamprenavir, • Phosphazid, • Entecavir, • Enfuvirtid, • Efavirenz, • Nelfinavir 

Drug List: Subsidiary Drug Supply System

(DLO)

• Anastrozole• Kapecitabin

• Paclitaxel• Temozolomid• Trastuzumab

• Imatinib• Rituximab

Program “7 expensive diseases”:bortezomib,

imatinib,

rituximab,

fludarabin

Reimbursement for oncological drugs

Рынок онкологических препаратов в стоимостном выражении, 2003 – 2006 гг.

142,0

400,2

174,1

790,5

23

98

130

0

100

200

300

400

500

600

700

800

900

2003 2004 2005

2006

Млн

дол

л.

-20

0

20

40

60

80

100

120

140

При

рост

, %

USD Прирост USD

Market of drugs used for malignanciesU

SD

, m

illio

ns

Increase, %

Incr

ease

, %

53,6

54,5

30,0

16,9

46,4

45,5

31,3

17,8

38,7

65,3

0% 20% 40% 60% 80% 100%

2003

2004

2005

2006

Розничный сектор Госпитальный сектор ДЛО

Соотношение секторов рынка онкологических препаратовв стоимостном выражении (USD),2003 – 2006 гг.

Hospital, retail and DLO sales of drugs used for malignanciesPatients coasts increased from 75.3 mln USD to 133.5 mln

USD 

Retail Hospital DLO

Top-10 drugs used in oncology, 2007

Costs PacksGleevek (imatinib) 9,33 % Viferon (interferon) 13,60 %

Eprex (epoeitin α) 5,47 % Methyluracil 12,16 %

Vobenzym (combination of enzymes) 4,13 %

Cycloferon 10,54 %

Velcade (bortezomib) 4,12 % Cyclophosphane 7,24 %

Viferon (interferon) 4,03 % Interferon 6,65 %

Mabtera (rituximab) 3,63 %Vobenzym (combination of enzymes)

5,54 %

Zometa (zolendronic acid) 3,63 % Grippferon (interferon) 4,47 %

Herceptin (trastuzumab) 3,29 % Methotrexate 2,80 %

Arimidex (anastrozole) 3,02 % Doxorubicin 2,72 %

Avastin (bevacizumab) 2,41 % Tamoxifen 2,31 %

Reforms in health care: how can they affect the access to

drugs?

Reforms

• There are no real reforms in health care not (over the past decade – no any fundamental law on health care)

• The concept of the pharmaceutical industry development – focus on profitable drugs  (even with questionable effectiveness), without taking into account the needs of society and patients

• There is no clear vision for health development 

What is necessary? 

• The establishment of reference prices• A unified list of essential medicines – priority

of financing• Distribution of reimbursement on all

population• Federal financing for rare, expensive drugs  • Other logistics of the delivery of medicines

to patients 

AcknowledgementAcknowledgement• Vlasov V. V. • Danishevskiy K.D. • Kornysheva E.A. • Saversky A.V. • Vorobiev A.P. • Aleinikova I.B. • Karev A. • Pletnev R.I. • Novikova J.V. • Svetlakova D.S. • Suleimanov C. S. • Baturin V.A.

• Vezikova N.N. • Avksenteva M.V.• Andrushenko E.V.• Basistova A.A.• Denisov A.U.• Kopylov K.G.• Kostikova O.M.• Kotenko O.N.• Litvinov A.B.• Nikitin E.A. • Ostrovskaya E.V.