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Too Costly & Too Scarce

Ewen, M.A.

2016

document version

Publisher's PDF, also known as Version of record

Link to publication in VU Research Portal

citation for published version (APA)

Ewen, M. A. (2016). Too Costly & Too Scarce: Price, availability and affordability of medicines in low- and middle-income countries.

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ϭϭϵ

7

ϭϮϬ

dĂďůĞϭ͗<ĞLJĨĞĂƚƵƌĞƐŽĨƚŚĞt,Kͬ,/ƚŽŽůĨŽƌŵĞĂƐƵƌŝŶŐƉƌŝĐĞƐĂŶĚĂǀĂŝůĂďŝůŝƚLJŽĨůŽĐĂůůLJƉƌŽĚƵĐĞĚ and imported medicines

ŶƐǁĞƌƐƚŚĞƐĞ ŬĞLJƋƵĞƐƟŽŶƐ • tŚĂƚƉƌŝĐĞƐĚŽĞƐƚŚĞŐŽǀĞƌŶŵĞŶƚƉĂLJ͕ĂŶĚƋƵĂŶƟƟĞƐƉƌŽĐƵƌĞĚ͕ĨŽƌƐĞůĞĐƚĞĚŵĞĚŝĐŝŶĞƐ ƚŚĂƚĂƌĞůŽĐĂůůLJƉƌŽĚƵĐĞĚĂŶĚŝŵƉŽƌƚĞĚ͕ĂŶĚŚŽǁĚŽƚŚĞƐĞƉƌŝĐĞƐĐŽŵƉĂƌĞĚǁŝƚŚƉƵďůŝĐ ƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐ͍ • tŚĂƚŝƐƚŚĞĂǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞĨŽƌŵĞĚŝĐŝŶĞƐƚŚĂƚĂƌĞůŽĐĂůůLJƉƌŽĚƵĐĞĚĂŶĚ ŝŵƉŽƌƚĞĚ͕ŝŶĚŝīĞƌĞŶƚƐĞĐƚŽƌƐĂŶĚƌĞŐŝŽŶƐŽĨƚŚĞĐŽƵŶƚƌLJ͍ • ŽƉƌŝĐĞƐĂŶĚĂǀĂŝůĂďŝůŝƚLJǀĂƌLJďLJƉƌŽĚƵĐƚƚLJƉĞ;ŽƌŝŐŝŶĂƚŽƌďƌĂŶĚ͕ďƌĂŶĚĞĚŐĞŶĞƌŝĐĂŶĚ /EEŐĞŶĞƌŝĐͿ͍ • ,ŽǁĚŽƉƌŝĐĞƐĐŽŵƉĂƌĞǁŝƚŚŝŶƚĞƌŶĂƟŽŶĂůƌĞĨĞƌĞŶĐĞƉƌŝĐĞƐ͍ • ,ŽǁĚŽƉƌŝĐĞƐǀĂƌLJďLJĐŽƵŶƚƌLJŽĨŵĂŶƵĨĂĐƚƵƌĞ͍ Data collected and sampling

ǀailaďiliƚLJ anĚ paƟĞnƚ pƌiĐĞƐ͗

• ^ƵƌǀĞLJĂƌĞĂƐ͗ĐĂƉŝƚĂůĐŝƚLJĂŶĚϱŽƚŚĞƌƌĞŐŝŽŶƐŽĨƚŚĞĐŽƵŶƚƌLJ • ^ĞĐƚŽƌƐ͗ƉƵďůŝĐ͕ƉƌŝǀĂƚĞĂŶĚŽŶĞŽƚŚĞƌƐĞĐƚŽƌ

• ^ĂŵƉůĞ͗ϱŵĞĚŝĐŝŶĞŽƵƚůĞƚƐƉĞƌƐƵƌǀĞLJƌĞŐŝŽŶƉĞƌƐĞĐƚŽƌ

'ŽǀĞƌnmĞnƚ pƌŽĐƵƌĞmĞnƚ pƌiĐĞƐ anĚ ƋƵanƟƟĞƐ͗ĐŽůůĞĐƚĞĚĨƌŽŵƉƌŽĐƵƌĞŵĞŶƚĚĞƉĂƌƚŵĞŶƚ

or Central Medical Store

ϭϮϯ

7

ƵŶĚĞƌĂďƌĂŶĚŶĂŵĞ͘Ŷ/EEŐĞŶĞƌŝĐŝƐĂŐĞŶĞƌŝĐĞƋƵŝǀĂůĞŶƚƉƌŽĚƵĐƚŵĂƌŬĞƚĞĚƵŶĚĞƌŝƚƐ /EEŶĂŵĞ͘

Z^h>d^

Ethiopia

'oǀernment procƵrement prices anĚ ƋƵanƟƟes

ĐƌŽƐƐ ƚŚĞ ŵĞĚŝĐŝŶĞƐ͕ ƚŚĞ ŐŽǀĞƌŶŵĞŶƚ ƉƌŽĐƵƌĞĚ ϰϴ ůŽĐĂůůLJ ƉƌŽĚƵĐĞĚ ƉƌŽĚƵĐƚƐ ĂŶĚ ϭϯ ŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ͘ĂƐĞĚŽŶƚŚĞ/EKƚĞƌŵƐ͕ϮϮйǁĂƐĂĚĚĞĚƚŽƚŚĞƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞ ŽĨŶŝŶĞƉƌŽĚƵĐƚƐĨŽƵŶĚƚŽďĞ&ƌĞĞĂƌƌŝĞƌŽƌ&ƌĞĞŽŶŽĂƌĚ;ϭϱйĨƌĞŝŐŚƚ͕Ϭ͘ϱйŝŶƐƵƌĂŶĐĞ͕ ϭ͘ϱйďĂŶŬĐŚĂƌŐĞƐ͕ϱйŝŵƉŽƌƚĚƵƚLJͿĂŶĚϳйǁĂƐĂĚĚĞĚƚŽĨŽƵƌƉƌŽĚƵĐƚƐĨŽƵŶĚƚŽďĞŽƐƚ ĂŶĚ&ƌĞŝŐŚƚ;Ϭ͘ϱйŝŶƐƵƌĂŶĐĞ͕ϭ͘ϱйďĂŶŬĐŚĂƌŐĞƐ͕ϱйŝŵƉŽƌƚĚƵƚLJͿ͘ KǀĞƌĂůů͕ƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐĨŽƌůŽĐĂůůLJƉƌŽĚƵĐĞĚĂŶĚŝŵƉŽƌƚĞĚŵĞĚŝĐŝŶĞƐǁĞƌĞϭ͘ϮϬĂŶĚ Ϭ͘ϴϰƟŵĞƐŝŶƚĞƌŶĂƟŽŶĂůƌĞĨĞƌĞŶĐĞƉƌŝĐĞƐ;/ZWͿ͕ƌĞƐƉĞĐƟǀĞůLJ;dĂďůĞϯͿ͘&ŽƌůŽĐĂůƉƌŽĚƵĐƚƐ͕ ŚĂůĨƌĂŶŐĞĚĨƌŽŵϬ͘ϵϵͲϭ͘ϯϯƟŵĞƐ/WZƐ͕ǁŚĞƌĞĂƐĨŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐŚĂůĨǁĞƌĞϬ͘ϳϳʹϭ͘Ϯϲ ƟŵĞƐ/ZWƐ͘

ϭϮϰ dĂ ďůĞϰ͗ Gov ernmen t pr ocur emen t prices in E thiopia f o

r medicines both loc

ally pr

oduced and import

ϭϮϱ

7

dĂ ďůĞϰ͗ Gov ernmen t pr ocur emen t prices in E thiopia f o

r medicines both loc

ally pr

oduced and import

ϭϮϲ ůŽĐĂůůLJƉƌŽĚƵĐĞĚƉŚĞŶŽďĂƌďŝƚŽŶĞǁŚŝĐŚǁĂƐĂƚŚŝƌĚŽĨƚŚĞƉƌŝĐĞŽĨƚŚĞŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚ͘ &ŽƌƚŚĞƐĞĞŝŐŚƚŵĞĚŝĐŝŶĞƐ͕ƚŚĞŐŽǀĞƌŶŵĞŶƚǁŽƵůĚŚĂǀĞƐĂǀĞĚĂďŽƵƚΨϯ͘ϳŵŝůůŝŽŶh^ŝĨ ŽŶůLJƚŚĞŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐǁĞƌĞƉƌŽĐƵƌĞĚ͘ ǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞƐŝŶƚŚĞƉƵďůŝĐƐĞĐƚŽƌ dŚĞ ŵĞĂŶ ĂǀĂŝůĂďŝůŝƚLJ ŽĨ ƚŚĞ ŵĞĚŝĐŝŶĞƐ ;ǁŚĞƚŚĞƌ ŝŵƉŽƌƚĞĚ Žƌ ůŽĐĂůůLJ ƉƌŽĚƵĐĞĚͿ ŝŶ ƚŚĞ ƉƵďůŝĐ ƐĞĐƚŽƌ ŽƵƚůĞƚƐ ǁĂƐ ϲϰй ;dĂďůĞ ϱͿ͘ >ŽĐĂů ƉƌŽĚƵĐƚƐ ŚĂĚ ŐƌĞĂƚĞƌ ŵĞĂŶ ĂǀĂŝůĂďŝůŝƚLJ ;ϰϴйͿƚŚĂŶŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ;ϭϵйͿ͘dŚĞĂǀĂŝůĂďŝůŝƚLJĨŽƌŝŶĚŝǀŝĚƵĂůŵĞĚŝĐŝŶĞƐǁĂƐŚŝŐŚůLJ ǀĂƌŝĂďůĞ͘ƌĂŶĚĞĚŐĞŶĞƌŝĐƐ;ϯϳйͿǁĞƌĞŵŽƌĞĐŽŵŵŽŶůLJĨŽƵŶĚƚŚĂŶ/EEŐĞŶĞƌŝĐƐ;ϭϰйͿĨŽƌ ůŽĐĂůƉƌŽĚƵĐƚƐ͕ǁŚĞƌĞĂƐĨŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐƚŚĞĂǀĂŝůĂďŝůŝƚLJŽĨďƌĂŶĚĞĚŐĞŶĞƌŝĐƐ;ϭϬйͿ ǁĂƐƐŝŵŝůĂƌƚŽ/EEŐĞŶĞƌŝĐƐ;ϵйͿ͘EŽŽƌŝŐŝŶĂƚŽƌďƌĂŶĚƐǁĞƌĞĨŽƵŶĚŝŶƚŚĞƉƵďůŝĐƐĞĐƚŽƌ͘ dĂďůĞϱ͗ǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞƐŝŶƚŚŝŽƉŝĂ͕ƉƵďůŝĐƐĞĐƚŽƌ͕ĨŽƌůŽĐĂůůLJƉƌŽĚƵĐĞĚĂŶĚŝŵƉŽƌƚĞĚ medicines >ŽĐĂůůLJ ƉƌŽĚƵĐĞĚ /ŵƉŽƌƚĞĚ Availability DĞĂŶĂǀĂŝůĂďŝůŝƚLJŽĨĂůůƉƌŽĚƵĐƚƐ;ůŽĐĂůĂŶĚŝŵƉŽƌƚĞĚͿĂŶĚ product types ϲϰй Mean availability of all product types

• KƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ • Branded generics • /EEŐĞŶĞƌŝĐƐ ϰϴй Ϭй ϯϳй ϭϰй ϭϵй Ϭй ϭϬй ϵй WĂƟĞŶƚƉƌŝĐĞƐ EƵŵďĞƌŽĨŵĞĚŝĐŝŶĞƐ;ƉƌŽĚƵĐƚƐͿ ϭϬ;ϭϳϳͿ ϭϬ;ϭϮϵͿ Median MPR ϭ͘ϰϰ ϭ͘ϭϴ DĞĚŝĂŶŝŶƚĞƌƋƵĂƌƟůĞƌĂŶŐĞ ϭ͘Ϭϴʹϭ͘ϱϲ ϭ͘ϬϮ͵ϭ͘ϰϮ DĞĚŝĂŶDWZ;ƉƌŽĚƵĐƚƐͿΎ • KƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ • Branded generics • /EEŐĞŶĞƌŝĐƐ Ͳ ϭ͘ϰϭ;ϯϯϭͿ ϭ͘ϰϱ;ϭϮϱͿ Ͳ ϭ͘ϭϰ;ϴϵͿ ϭ͘ϰϭ;ϳϵͿ *Unpaired analysis of prices

ϭϮϳ

7

ĐƌŽƐƐĂůůŵĞĚŝĐŝŶĞƐ;ƵŶƉĂŝƌĞĚͿ͕ƉĂƟĞŶƚƐŝŶƚŚĞƉƵďůŝĐƐĞĐƚŽƌǁĞƌĞƉĂLJŝŶŐϮϯйŵŽƌĞĨŽƌ ůŽĐĂůůLJƉƌŽĚƵĐĞĚďƌĂŶĚĞĚŐĞŶĞƌŝĐƐ;ŵĞĚŝĂŶDWZсϭ͘ϰϭͿƚŚĂŶŝŵƉŽƌƚƐ;ŵĞĚŝĂŶDWZсϭ͘ϭϰͿ͘ &Žƌ/EEŐĞŶĞƌŝĐƐ͕ƚŚĞĚŝīĞƌĞŶĐĞǁĂƐŵŝŶŝŵĂů͘ WƵďůŝĐƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐĐŽŵƉĂƌĞĚƚŽŐŽǀĞƌŶŵĞŶƚƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐ ĐƌŽƐƐ ƚŚĞ ϮϬ ůŽĐĂůůLJ ƉƌŽĚƵĐĞĚ ŵĞĚŝĐŝŶĞƐ ƚŚĂƚ ƚŚĞ ŐŽǀĞƌŶŵĞŶƚ ƉƌŽĐƵƌĞĚ ĂŶĚ ƐŽůĚ ƚŽ ƉĂƟĞŶƚƐ ŝŶ ƉƵďůŝĐ ƐĞĐƚŽƌ ŽƵƚůĞƚƐ͕ ƉĂƟĞŶƚƐ ǁĞƌĞ ƉĂLJŝŶŐ ϭ͘ϭϳ ƟŵĞƐ ;ϭϳй ŵŽƌĞ ƚŚĂŶͿ ƚŚĞ ŐŽǀĞƌŶŵĞŶƚƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞ;dĂďůĞϲͿ͘&ŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ;ϵŵĞĚŝĐŝŶĞƐͿ͕ƉĂƟĞŶƚƐ ǁĞƌĞƉĂLJŝŶŐϭ͘ϱϯƟŵĞƐ;ϱϯйŵŽƌĞƚŚĂŶͿƚŚĞƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞ͘ dĂďůĞϲ͗DĞĚŝĂŶƌĂƟŽďĞƚǁĞĞŶƉƵďůŝĐƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐĂŶĚƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐŝŶƚŚŝŽƉŝĂĨŽƌ locally produced and imported medicines

ϭϮϴ

dĂďůĞϳ͗^ƵŵŵĂƌLJŽĨĂǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞƐŝŶƚŚŝŽƉŝĂ͕ƉƌŝǀĂƚĞƐĞĐƚŽƌ͕ĨŽƌůŽĐĂůůLJƉƌŽĚƵĐĞĚ and imported medicines

>ŽĐĂůůLJƉƌŽĚƵĐĞĚ /ŵƉŽƌƚĞĚ

Availability DĞĂŶĂǀĂŝůĂďŝůŝƚLJŽĨĂůůƉƌŽĚƵĐƚƐ;ůŽĐĂůĂŶĚŝŵƉŽƌƚĞĚͿ and product types

ϳϯй Mean availability of all product types

• KƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ • Branded generics • /EEŐĞŶĞƌŝĐƐ ϱϰй Ϭй ϰϮй ϭϯй ϯϱй ϵй Ϯϵй ϯй WĂƟĞŶƚƉƌŝĐĞƐ EƵŵďĞƌŽĨŵĞĚŝĐŝŶĞƐ;ƉƌŽĚƵĐƚƐͿ ϭϱ;ϯϬϲͿ ϭϱ;ϰϬϯͿ Median MPR ϭ͘ϴϱ ϱ͘ϰϮ DĞĚŝĂŶŝŶƚĞƌƋƵĂƌƟůĞƌĂŶŐĞ ϭ͘ϳϭʹϭ͘ϵϲ Ϯ͘ϲϱʹϵ͘ϯϰ DĞĚŝĂŶDWZ;ƉƌŽĚƵĐƚƐͿΎ • KƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ • Branded generics • /EEŐĞŶĞƌŝĐƐ ʹ ϭ͘ϳϭ;ϯϯϬͿ Ϯ͘ϭϳ;ϵϴͿ ϮϬ͘ϯϱ;ϲϵͿ ϰ͘ϯϯ;ϰϭϭͿ Ϯ͘Ϭϴ;ϮϱͿ *Unpaired analysis of prices

Tanzania

'oǀernment procurement prices and ƋuanƟƟes

&ŽƌĞĂĐŚŵĞĚŝĐŝŶĞƉƌŽĐƵƌĞĚďLJƚŚĞŐŽǀĞƌŶŵĞŶƚ͕ůŽĐĂůůLJƉƌŽĚƵĐĞĚŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ ǁĞƌĞƉƵƌĐŚĂƐĞĚďƵƚŶŽƚďŽƚŚ͘ƚŽƚĂůŽĨŶŝŶĞůŽĐĂůƉƌŽĚƵĐƚƐĂŶĚƚĞŶŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ ǁĞƌĞ ƉƌŽĐƵƌĞĚ͘ ĂƐĞĚ ŽŶ ƚŚĞ /EK ƚĞƌŵƐ͕ ŶŽ ƉƌŝĐĞ ĂĚũƵƐƚŵĞŶƚƐ ǁĞƌĞ ŶĞĞĚĞĚ͘ KǀĞƌĂůů͕ ŐŽǀĞƌŶŵĞŶƚ ƉƌŽĐƵƌĞŵĞŶƚ ƉƌŝĐĞƐ ĨŽƌ ůŽĐĂů ĂŶĚ ŝŵƉŽƌƚĞĚ ƉƌŽĚƵĐƚƐ ǁĞƌĞ Ϭ͘ϲϵ ĂŶĚ ϭ͘ϯϰ ƟŵĞƐ /ZWƐ͕ ƌĞƐƉĞĐƟǀĞůLJ ;dĂďůĞ ϴͿ͘ &Žƌ ůŽĐĂů ƉƌŽĚƵĐƚƐ͕ ŚĂůĨ ƌĂŶŐĞĚ ĨƌŽŵ Ϭ͘ϲϱʹϬ͘ϵϳ ƟŵĞƐ /ZWƐ͕ǁŚĞƌĞĂƐĨŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐŚĂůĨǁĞƌĞϬ͘ϲϵʹϰ͘ϴϱƟŵĞƐ/ZWƐ͘

ǀailabilitLJ and paƟent prices in the public sector

ϭϮϵ

7

WƵďůŝĐƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐĨŽƌůŽĐĂůƉƌŽĚƵĐƚƐǁĞƌĞŚŝŐŚĞƌƚŚĂŶŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐĂĐƌŽƐƐ ƚŚĞ ϵ ŵĞĚŝĐŝŶĞƐ ŝŶ ƚŚĞ ƉĂŝƌĞĚ ĂŶĂůLJƐŝƐ ;dĂďůĞ ϴͿ͘ DĞĚŝĂŶ DWZƐ ŽĨ ůŽĐĂů ĂŶĚ ŝŵƉŽƌƚĞĚ ƉƌŽĚƵĐƚƐǁĞƌĞϭ͘ϰϰĂŶĚϭ͘ϯϱƌĞƐƉĞĐƟǀĞůLJ͕ŚĞŶĐĞƉĂƟĞŶƚƐǁĞƌĞƉĂLJŝŶŐϳйŵŽƌĞĨŽƌůŽĐĂů products. /Ŷ ĂŶ ƵŶƉĂŝƌĞĚ ĂŶĂůLJƐŝƐ ŽĨ Ăůů ŵĞĚŝĐŝŶĞƐ ƐŽůĚ ƚŽ ƉĂƟĞŶƚƐ ŝŶ ƚŚĞ ƉƵďůŝĐ ƐĞĐƚŽƌ͕ ůŽĐĂůůLJ ƉƌŽĚƵĐĞĚ ďƌĂŶĚĞĚ ŐĞŶĞƌŝĐƐ ǁĞƌĞ Ϯϰй ůŽǁĞƌ ƉƌŝĐĞĚ ;ŵĞĚŝĂŶ DWZсϭ͘ϲϳͿ ƚŚĂŶ ŝŵƉŽƌƚĞĚ ďƌĂŶĚĞĚ ŐĞŶĞƌŝĐƐ ;ŵĞĚŝĂŶ DWZсϮ͘ϮϬͿ͘ &Žƌ /EE ŐĞŶĞƌŝĐƐ ƚŚĞƌĞ ǁĂƐ ǀŝƌƚƵĂůůLJ ŶŽ ƉƌŝĐĞ ĚŝīĞƌĞŶĐĞďĞƚǁĞĞŶŝŵƉŽƌƚƐĂŶĚƉƌŽĚƵĐƚƐŵĂĚĞŝŶdĂŶnjĂŶŝĂ;dĂďůĞϴͿ͘ dĂďůĞϴ͗^ƵŵŵĂƌLJŽĨƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐ͕ĂǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞƐŝŶdĂŶnjĂŶŝĂ͕ƉƵďůŝĐƐĞĐƚŽƌ͕ for locally produced and imported medicines

>ŽĐĂůůLJƉƌŽĚƵĐĞĚ /ŵƉŽƌƚĞĚ Government procurement prices* EƵŵďĞƌŽĨŵĞĚŝĐŝŶĞƐ;ƉƌŽĚƵĐƚƐͿ ϵ;ϵͿ ϳ;ϭϬͿ Median MPR Ϭ͘ϲϵ ϭ͘ϯϰ /ŶƚĞƌƋƵĂƌƟůĞƌĂŶŐĞ Ϭ͘ϲϱʹϬ͘ϵϳ Ϭ͘ϲϵʹϰ͘ϴϱ

Availability Mean availability of all products and product types ϱϮй Mean availability of all product types

KƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ • Branded generics • /EEŐĞŶĞƌŝĐƐ Ϯϭй Ϭй ϭϱй ϲй ϯϮй ϰй Ϯϳй ϱй WĂƟĞŶƚƉƌŝĐĞƐ EƵŵďĞƌŽĨŵĞĚŝĐŝŶĞƐ;ƉƌŽĚƵĐƚƐͿ ϵ;ϭϬϰͿ ϵ;ϭϬϳͿ Median MPR ϭ͘ϰϰ ϭ͘ϯϱ DĞĚŝĂŶŝŶƚĞƌƋƵĂƌƟůĞƌĂŶŐĞ ϭ͘ϬϬʹϭ͘ϴϱ ϭ͘Ϯϵʹϭ͘ϳϱ DĞĚŝĂŶDWZ;ƉƌŽĚƵĐƚƐͿΎ • KƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ • Branded generics • /EEŐĞŶĞƌŝĐƐ ʹ ϭ͘ϲϳ;ϭϮϭͿ ϭ͘ϵϴ;ϰϵͿ ϯ͘ϰϴ;ϰϮͿ Ϯ͘ϮϬ;ϮϯϬͿ ϭ͘ϵϳ;ϯϲͿ *Unpaired analysis of prices

WƵďůŝĐƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐĐŽŵƉĂƌĞĚƚŽŐŽǀĞƌŶŵĞŶƚƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐ

ϭϯϬ

dĂďůĞϵ͗DĞĚŝĂŶƌĂƟŽďĞƚǁĞĞŶƉƵďůŝĐƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐĂŶĚƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐŝŶdĂŶnjĂŶŝĂĨŽƌ locally produced and imported medicines

EƵŵďĞƌŽĨƉĂŝƌĞĚ ŵĞĚŝĐŝŶĞƐ DĞĚŝĂŶƌĂƟŽďĞƚǁĞĞŶWƵďůŝĐ^ĞĐƚŽƌWĂƟĞŶƚ WƌŝĐĞDWZĂŶĚWƵďůŝĐ^ĞĐƚŽƌWƌŽĐƵƌĞŵĞŶƚ WƌŝĐĞDWZ >ŽĐĂůůLJƉƌŽĚƵĐĞĚƉƌŽĚƵĐƚƐ ϴ Ϯ͘ϯϱ /ŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ ϳ ϭ͘ϲϱ Note: dŚŝƐĂŶĂůLJƐŝƐĚŽĞƐŶŽƚƵƐĞ/ŶƚĞƌŶĂƟŽŶĂůZĞĨĞƌĞŶĐĞWƌŝĐĞƐ ǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞƐŝŶƚŚĞƉƌŝǀĂƚĞƐĞĐƚŽƌ dŚĞ ŵĞĂŶ ĂǀĂŝůĂďŝůŝƚLJ ŽĨ ŝŵƉŽƌƚĞĚ Žƌ ůŽĐĂůůLJ ƉƌŽĚƵĐĞĚ ŵĞĚŝĐŝŶĞƐ ǁĂƐ ϴϮй ŝŶ ƚŚĞ ƉƌŝǀĂƚĞƐĞĐƚŽƌ;dĂďůĞϭϬͿ͘ǀĂŝůĂďŝůŝƚLJŽĨůŽĐĂůĂŶĚŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐǁĂƐϮϭйĂŶĚϳϬй͕ ƌĞƐƉĞĐƟǀĞůLJ͕ǁŝƚŚǀĂƌŝĂďŝůŝƚLJĨŽƌŝŶĚŝǀŝĚƵĂůŵĞĚŝĐŝŶĞƐ͘ƐǁŝƚŚƚŚĞƉƵďůŝĐƐĞĐƚŽƌ͕ďƌĂŶĚĞĚ ŐĞŶĞƌŝĐƐǁĞƌĞŵŽƌĞĐŽŵŵŽŶůLJĨŽƵŶĚƚŚĂŶ/EEŐĞŶĞƌŝĐƐĨŽƌůŽĐĂůƉƌŽĚƵĐƚƐ;ϭϵйǀĞƌƐƵƐ ϮйͿĂŶĚŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ;ϱϴйǀĞƌƐƵƐϭϮйͿ͘EŽůŽĐĂůůLJƉƌŽĚƵĐĞĚŽƌŝŐŝŶĂƚŽƌďƌĂŶĚƐǁĞƌĞ ĨŽƵŶĚ͘dŚĞĂǀĂŝůĂďŝůŝƚLJŽĨŝŵƉŽƌƚĞĚŽƌŝŐŝŶĂƚŽƌďƌĂŶĚƐǁĂƐϳй͘ dĂďůĞϭϬ͗^ƵŵŵĂƌLJŽĨĂǀĂŝůĂďŝůŝƚLJĂŶĚƉĂƟĞŶƚƉƌŝĐĞƐŝŶdĂŶnjĂŶŝĂ͕ƉƌŝǀĂƚĞƐĞĐƚŽƌ͕ĨŽƌůŽĐĂůůLJƉƌŽĚƵĐĞĚ and imported medicines

>ŽĐĂůůLJƉƌŽĚƵĐĞĚ /ŵƉŽƌƚĞĚ

Availability Mean availability of all products and product types ϴϮй Mean availability of all product types

ϭϯϮ dŚĞƌĞĂƐŽŶƐĨŽƌƚŚŝƐƉƵƌĐŚĂƐŝŶŐƉƌĂĐƟĐĞǁĂƌƌĂŶƚĨƵƌƚŚĞƌƐƚƵĚLJ͘WĞƌŚĂƉƐƚŚĞŵĂŶƵĨĂĐƚƵƌĞƌƐ ǁĞƌĞƵŶĂďůĞƚŽƐƵƉƉůLJŐƌĞĂƚĞƌƋƵĂŶƟƟĞƐ͕ŽƌƚŚĞŐŽǀĞƌŶŵĞŶƚǁĂƐďƵLJŝŶŐĨƌŽŵŵƵůƟƉůĞ ůŽĐĂůŵĂŶƵĨĂĐƚƵƌĞƌƐƚŽƉƌŽǀŝĚĞďƌŽĂĚĞƌůŽĐĂůƐƵƉƉŽƌƚ͘dŚĞƚŚŝŽƉŝĂŶŐŽǀĞƌŶŵĞŶƚ͛ƐϮϱй ůŽĐĂůƉƌĞĨĞƌĞŶĐĞƉŽůŝĐLJǁĂƐďĞŝŶŐĞdžĐĞĞĚĞĚĨŽƌƐŽŵĞŵĞĚŝĐŝŶĞƐ͕ĂŶĚƐŝŐŶŝĮĐĂŶƚƐĂǀŝŶŐƐ ǁŽƵůĚƌĞƐƵůƚŝĨŽŶůLJůŽǁĞƌͲƉƌŝĐĞĚƉƌŽĚƵĐƚƐ;ŝŵƉŽƌƚƐͿǁĞƌĞƉƵƌĐŚĂƐĞĚ͘ /ŶƚĞƌĞƐƟŶŐůLJ͕ ƚŚĞ ƚŚŝŽƉŝĂŶ ŐŽǀĞƌŶŵĞŶƚ ĂƉƉůŝĞĚ Ă ƐŵĂůůĞƌ ŵĂƌŬͲƵƉ ŽŶ ŚŝŐŚĞƌͲƉƌŝĐĞĚ ůŽĐĂů ƉƌŽĚƵĐƚƐ ;ϭϳйͿ͕ ƚŚĂŶ ŽŶ ůŽǁĞƌͲƉƌŝĐĞĚ ŝŵƉŽƌƚĞĚ ƉƌŽĚƵĐƚƐ ;ϱϯйͿ͘ dŚŝƐ ƌĞĚƵĐĞĚ ƚŚĞ ĚŝīĞƌĞŶĐĞŝŶƉĂƟĞŶƚƉƌŝĐĞƐďĞƚǁĞĞŶůŽĐĂůĂŶĚŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐƚŽϮϮйŝŶƉƵďůŝĐƐĞĐƚŽƌ ŽƵƚůĞƚƐ͘ dŚŝƐ ŝůůƵƐƚƌĂƚĞƐ ŚŽǁ ƚŚĞ ŐŽǀĞƌŶŵĞŶƚ ƐƵƉƉŽƌƚƐ ůŽĐĂů ƉƌŽĚƵĐĞƌƐ͘ dŚĞ dĂŶnjĂŶŝĂŶ ŐŽǀĞƌŶŵĞŶƚǁĂƐĂůƐŽĂƉƉůLJŝŶŐǀĂƌŝĂďůĞƉƵďůŝĐƐĞĐƚŽƌŵĂƌŬͲƵƉƐŝ͘Ğ͘ϭϯϱйŽŶůŽǁĞƌͲƉƌŝĐĞĚ ůŽĐĂůƉƌŽĚƵĐƚƐĂŶĚϲϱйĨŽƌŚŝŐŚĞƌͲƉƌŝĐĞĚŝŵƉŽƌƚƐ͘dŚŝƐƌĞƐƵůƚĞĚŝŶŽŶůLJĂϳйĚŝīĞƌĞŶĐĞŝŶ ƉƵďůŝĐƐĞĐƚŽƌƉĂƟĞŶƚƉƌŝĐĞƐďĞƚǁĞĞŶůŽĐĂůĂŶĚŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ͘dŚĞƌĞǀĞŶƵĞŐĞŶĞƌĂƚĞĚ ďLJƚŚĞƐĞƉƌĂĐƟĐĞƐŝƐƌĞƚƵƌŶĞĚƚŽƚŚĞŐŽǀĞƌŶŵĞŶƚ͘ /ŶƚŚĞƉƌŝǀĂƚĞƐĞĐƚŽƌŝŶdĂŶnjĂŶŝĂ͕ƉĂƟĞŶƚƉƌŝĐĞƐǁĞƌĞƐŝŵŝůĂƌĨŽƌŝŵƉŽƌƚƐĂŶĚůŽĐĂůƉƌŽĚƵĐƚƐ͘ /ŶƚŚŝŽƉŝĂ͕ƉĂƟĞŶƚƐǁĞƌĞƉĂLJŝŶŐϭϵϯйŵŽƌĞĨŽƌŝŵƉŽƌƚƐĐŽŵƉĂƌĞĚƚŽůŽĐĂůůLJƉƌŽĚƵĐĞĚ ƉƌŽĚƵĐƚƐ͘dŚŝƐĂƉƉĂƌĞŶƚĐŽŶƐƵŵĞƌǁŝůůŝŶŐŶĞƐƐƚŽƉĂLJŚŝŐŚĞƌƉƌŝĐĞƐĨŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ ŵĂLJƌĞŇĞĐƚĂƉĞƌĐĞƉƟŽŶƚŚĂƚŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐŵĂLJďĞŽĨŚŝŐŚĞƌƋƵĂůŝƚLJ͘dŽƐƚůŽĐĂů industry the government may need to ensure and publicise the equivalent quality of locally produced products.

tŚĂƚŝƐƵŶŬŶŽǁŶ͕ŝŶƚŚĞƉƌŝǀĂƚĞƐĞĐƚŽƌƐŽĨďŽƚŚĐŽƵŶƚƌŝĞƐ͕ĂƌĞŵĞĚŝĐŝŶĞƉƌŝĐĞĐŽŵƉŽŶĞŶƚƐ ŝ͘Ğ͘ ŵĂŶƵĨĂĐƚƵƌĞƌ͛Ɛ ƐĞůůŝŶŐ ƉƌŝĐĞƐ͕ ŵĂƌŬͲƵƉƐ ĂŶĚ ŽƚŚĞƌ ĂĚĚͲŽŶƐ ŝŶ ƚŚĞ ƐƵƉƉůLJ ĐŚĂŝŶ ƚŚĂƚ ŵĂŬĞƵƉƚŚĞĮŶĂůƉĂƟĞŶƚƉƌŝĐĞ͘>ŽĐĂůŵĂŶƵĨĂĐƚƵƌĞƌƐŵĂLJďĞƐĞůůŝŶŐĂƚůŽǁĞƌƉƌŝĐĞƐďƵƚĂĚĚͲ ŽŶƐŵĂLJƐŝŐŶŝĮĐĂŶƚůLJŝŶĐƌĞĂƐĞƉĂƟĞŶƚƉƌŝĐĞƐŵĂŬŝŶŐƉƌŽĚƵĐƚƐůĞƐƐĂīŽƌĚĂďůĞĨŽƌƉĂƟĞŶƚƐ͘ DĂŶLJt,Kͬ,/ƐƵƌǀĞLJƐŚĂǀĞĨŽƵŶĚŝƚĐŚĂůůĞŶŐŝŶŐƚŽŵĞĂƐƵƌĞƉƌŝĐĞĐŽŵƉŽŶĞŶƚƐ;ϮͿ, so ŝŶƚŚŝƐƐƵƌǀĞLJƉƌŽĐƵƌĞŵĞŶƚĂŶĚƐĞůůŝŶŐƉƌŝĐĞƐǁĞƌĞŵĞĂƐƵƌĞĚĨŽƌŽŶůLJŽŶĞǁŚŽůĞƐĂůĞƌƉĞƌ ĐŽƵŶƚƌLJ͘dŚŝƐŚĂƐůŝŵŝƚĞĚǀĂůƵĞƐŽŝƐŶŽƚƌĞƉŽƌƚĞĚŚĞƌĞ͘,ŽǁĞǀĞƌ͕ŐŽǀĞƌŶŵĞŶƚƐƐƵƉƉŽƌƟŶŐ ůŽĐĂů ƉƌŽĚƵĐƟŽŶ ƐŚŽƵůĚ ĨƵůůLJ ŝŶǀĞƐƟŐĂƚĞ ƉƌŝĐĞ ĐŽŵƉŽŶĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ŵĂƌŬͲƵƉƐ͕ ůŽĐĂů ƚĂdžĞƐ͕ ƌĞďĂƚĞƐ ĂŶĚ ĚŝƐĐŽƵŶƚƐ͕ ƚŚĞŶ ƌĞŐƵůĂƚĞ ŵĂƌŬĞƚƐ ƚŽ ĞŶƐƵƌĞ ƚŚĞŝƌ ƐƵƉƉŽƌƚ ƌĞƐƵůƚƐ ŝŶ ŵŽƌĞĂīŽƌĚĂďůĞŵĞĚŝĐŝŶĞƐĨŽƌƉĂƟĞŶƚƐ͘^ŽƵƚŚĨƌŝĐĂŚĂƐĐŚŽƐĞŶƚŽƵƐĞĂ^ŝŶŐůĞdžŝƚWƌŝĐĞ ;^WͿŵĞĐŚĂŶŝƐŵƚŚĂƚďĂŶƐĚŝƐĐŽƵŶƚƐĂŶĚƌĞďĂƚĞƐĂŶĚƉƌŽǀŝĚĞƐƚƌĂŶƐƉĂƌĞŶƚŝŶĨŽƌŵĂƟŽŶ about the prices of medicines sold in the private sector ;ϭϰͿ.

ϭϯϯ

7

KE>h^/KE^

dŚĞĨŽůůŽǁŝŶŐĂƌĞŽƵƌŬĞLJƌĞĐŽŵŵĞŶĚĂƟŽŶƐ͗

• Systems to regularly and reliably monitor the availability and prices of locally produced ĂŶĚŝŵƉŽƌƚĞĚŵĞĚŝĐŝŶĞƐŶĞĞĚƚŽďĞĞƐƚĂďůŝƐŚĞĚƚŽĂƐƐĞƐƐƚŚĞŝŵƉĂĐƚŽĨůŽĐĂůƉƌŽĚƵĐƟŽŶ policies on access to medicines.

• 'ŽǀĞƌŶŵĞŶƚƐ ƐƵƉƉŽƌƟŶŐ ůŽĐĂů ƉƌŽĚƵĐƟŽŶ ŶĞĞĚ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ǁŚĞƌĞ ƚŚĞ ƉƌŝĐĞƐ ŽĨ locally produced medicines are found to be higher than imported ones, they adopt appropriate policies so that ŚŝŐŚƉƌŝĐĞƐĂƌĞŶŽƚƉĂƐƐĞĚŽŶƚŽƉĂƟĞŶƚƐ͕ĂƐƚŚŝƐŝƐĐŽŶƚƌĂƌLJ ƚŽƚŚĞŽďũĞĐƟǀĞŽĨŝŵƉƌŽǀŝŶŐĂĐĐĞƐƐƚŚƌŽƵŐŚůŽĐĂůƉƌŽĚƵĐƟŽŶ͘

• Where government procurement prices of locally produced products are higher than ŝŵƉŽƌƚƐ;ĂƐŝŶƚŚĞĐĂƐĞŽĨƚŚŝŽƉŝĂͿ͕ƚŚĞƉƌŽĐƵƌĞŵĞŶƚƉƌŝĐĞƐŽĨallŵĞĚŝĐŝŶĞƐ;ŝŵƉŽƌƚĞĚ ĂŶĚ ůŽĐĂůůLJ ƉƌŽĚƵĐĞĚͿ ƐŚŽƵůĚ ƚŚĞŶ ďĞ ƌĞǀŝĞǁĞĚ͘ >ŽĐĂů ƉƌĞĨĞƌĞŶĐĞƐ ƐŚŽƵůĚ ĂůƐŽ ďĞ ƌĞǀŝĞǁĞĚƚŽĞŶƐƵƌĞŵĞĚŝĐŝŶĞƐĂƌĞĂīŽƌĚĂďůĞƚŽƚŚĞƉŽƉƵůĂƟŽŶ͘>ŽǁĞƌƉƌŽĐƵƌĞŵĞŶƚ ƉƌŝĐĞƐ͕ǁŚĞƚŚĞƌĨŽƌůŽĐĂůŽƌŝŵƉŽƌƚĞĚƉƌŽĚƵĐƚƐ͕ƐŚŽƵůĚďĞƉĂƐƐĞĚŽŶƚŽƉĂƟĞŶƚƐ͘ • ^ƵƉƉŽƌƟŶŐ ůŽĐĂů ŵĂŶƵĨĂĐƚƵƌĞƌƐ ƚŚƌŽƵŐŚ ĮƐĐĂů ĂŶĚͬŽƌ ŶŽŶͲĮƐĐĂů ŝŶĐĞŶƟǀĞƐ ŵƵƐƚ ďĞ ƟŵĞͲďŽƵŶĚ͕ ĚĞǀĞůŽƉĞĚ ĂŶĚ ŝŵƉůĞŵĞŶƚĞĚ ŝŶ Ă ƚƌĂŶƐƉĂƌĞŶƚ ǁĂLJ͕ ĂŶĚ ŶŽƚ ƉĂŝĚ ďLJ ƉĂƟĞŶƚƐƚŚƌŽƵŐŚŚŝŐŚĞƌŵĞĚŝĐŝŶĞƉƌŝĐĞƐ͘ĂůĂŶĐŝŶŐůŽĐĂůƉƌŽĚƵĐƟŽŶƉŽůŝĐŝĞƐŝƐĐƌŝƟĐĂůůLJ ŝŵƉŽƌƚĂŶƚ͘ ^ƵĐŚ ƉŽůŝĐŝĞƐ ƐŚŽƵůĚ ĞŶĐŽƵƌĂŐĞ ĨŽƌĞŝŐŶ ŝŶǀĞƐƚŵĞŶƚƐ ŝŶ ƉŚĂƌŵĂĐĞƵƟĐĂů manufacturing in developing countries.

ϭϯϰ

Z&ZE^

ϭ͘ t,K͘tŽƌůĚDĞĚŝĐŝŶĞƐ^ƚƌĂƚĞŐLJϮϬϬϰͲϮϬϬϳ͘'ĞŶĞǀĂ͗t,K͕ϮϬϬϰ͘ Ϯ͘ ĂŵĞƌŽŶ͕ǁĞŶD͕ZŽƐƐͲĞŐŶĂŶ͕Ăůů͕>ĂŝŶŐZ͘DĞĚŝĐŝŶĞƉƌŝĐĞƐ͕ĂǀĂŝůĂďŝůŝƚLJ͕ĂŶĚĂīŽƌĚĂďŝůŝƚLJŝŶ ϯϲĚĞǀĞůŽƉŝŶŐĂŶĚŵŝĚĚůĞͲŝŶĐŽŵĞĐŽƵŶƚƌŝĞƐ͗ĂƐĞĐŽŶĚĂƌLJĂŶĂůLJƐŝƐ͘dŚĞ>ĂŶĐĞƚ͖ϯϳϯ;ϵϲϱϵͿ͗ϮϰϬʹϮϰϵ͘ ϯ͘ sĂŶDŽƵƌŝŬD^D͕ĂŵĞƌŽŶ͕ǁĞŶD͕>ĂŝŶŐZK͘ǀĂŝůĂďŝůŝƚLJ͕ƉƌŝĐĞĂŶĚĂīŽƌĚĂďŝůŝƚLJŽĨĐĂƌĚŝŽǀĂƐĐƵůĂƌ ŵĞĚŝĐŝŶĞƐ͗ĂĐŽŵƉĂƌŝƐŽŶĂĐƌŽƐƐϯϲĐŽƵŶƚƌŝĞƐƵƐŝŶŐt,Kͬ,/ĚĂƚĂ͘DĂƌĚŝŽǀĂƐĐŝƐŽƌĚϮϬϭϬ͖ϭϬ͗Ϯϱ͘ ϰ͘ sŽůŵĂŶ ͘ ŝƌĞĐƚ ĐŽƐƚƐ ĂŶĚ ĂǀĂŝůĂďŝůŝƚLJ ŽĨ ĚŝĂďĞƚĞƐ ŵĞĚŝĐŝŶĞƐ ŝŶ ůŽǁͲ ĂŶĚ ŵŝĚĚůĞͲŝŶĐŽŵĞ ĐŽƵŶƚƌŝĞƐ͘ t,Kͬ,/ϮϬϬϴ͘ŚƩƉ͗ͬͬŚĂŝǁĞď͘ŽƌŐͬƉƌŝĐŝŶŐͲƉƵďůŝĐĂƟŽŶƐͬ ϱ͘ ĂŵĞƌŽŶ͕ĂŶƐĂů͕ƵĂd͕,ŝůů^͕DŽƐŚĞ^͕DĂŶƚĞůͲdĞĞƵǁŝƐƐĞ͕^ĂdžĞŶĂ^͘DĂƉƉŝŶŐƚŚĞĂǀĂŝůĂďŝůŝƚLJ͕ ƉƌŝĐĞ ĂŶĚ ĂīŽƌĚĂďŝůŝƚLJ ŽĨ ĂŶƟĞƉŝůĞƉƟĐ ĚƌƵŐƐ ŝŶ ϰϲ ĐŽƵŶƚƌŝĞƐ͘ ƉŝůĞƉƐŝĂ ϮϬϭϮ :ƵŶ͖ϱϯ;ϲͿ͗ϵϲϮͲϵ͘ ĚŽŝ͗ ϭϬ͘ϭϭϭϭͬũ͘ϭϱϮϴͲϭϭϲϳ͘ϮϬϭϮ͘Ϭϯϰϰϲ͘dž ϲ͘ 'ĞůĚĞƌƐ^͕ǁĞŶD͕EŽŐƵĐŚŝE͕>ĂŝŶŐZ͘WƌŝĐĞ͕ĂǀĂŝůĂďŝůŝƚLJĂŶĚĂīŽƌĚĂďŝůŝƚLJ͘ŶŝŶƚĞƌŶĂƟŽŶĂůĐŽŵƉĂƌŝƐŽŶ ŽĨĐŚƌŽŶŝĐĚŝƐĞĂƐĞŵĞĚŝĐŝŶĞƐ͘t,KDZKͬ,/ϮϬϬϲ͘ ϳ͘ t,K͘ >ŽĐĂů ƉƌŽĚƵĐƟŽŶ ĨŽƌ ĂĐĐĞƐƐ ƚŽ ŵĞĚŝĐĂů ƉƌŽĚƵĐƚƐ͘ ĞǀĞůŽƉŝŶŐ Ă ĨƌĂŵĞǁŽƌŬ ƚŽ ŝŵƉƌŽǀĞ ƉƵďůŝĐ ŚĞĂůƚŚ͘'ĞŶĞǀĂ͗t,K͕ƐƐĞŶƟĂůDĞĚŝĐŝŶĞƐĂŶĚWƌŽĚƵĐƚƐ͗WŽůŝĐLJďƌŝĞĨ͕ϮϬϭϰ͘ ϴ͘ <ĂƉůĂŶt͘>ŽĐĂůƉƌŽĚƵĐƟŽŶĂŶĚĂĐĐĞƐƐƚŽŵĞĚŝĐŝŶĞƐŝŶůŽǁͲĂŶĚŵŝĚĚůĞͲŝŶĐŽŵĞĐŽƵŶƚƌŝĞƐ͘ůŝƚĞƌĂƚƵƌĞ ƌĞǀŝĞǁĂŶĚĐƌŝƟĐĂůĂŶĂůLJƐŝƐ͘'ĞŶĞǀĂ͗t,K͕ϮϬϭϯ ϵ͘ DƵũŝŶũĂW͕DĂĐŬŝŶƚŽƐŚD͕:ƵƐƟŶͲdĞŵƵD͕tƵLJƚƐD͘>ŽĐĂůƉƌŽĚƵĐƟŽŶŽĨƉŚĂƌŵĂĐĞƵƟĐĂůƐŝŶĨƌŝĐĂĂŶĚ ĂĐĐĞƐƐƚŽĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐ͚͗ƵƌďĂŶďŝĂƐ͛ŝŶĂĐĐĞƐƐƚŽŝŵƉŽƌƚĞĚŵĞĚŝĐŝŶĞƐŝŶdĂŶnjĂŶŝĂĂŶĚŝƚƐƉŽůŝĐLJ ŝŵƉůŝĐĂƟŽŶƐ͘'lobalinjaƟon and ,ealthϮϬϭϰ͖ϭϬ͗ϭϮ͘

ϭϬ͘ dŚĞtŽƌůĚĂŶŬ͘WƌŽĐƵƌĞŵĞŶƚŽĨŐŽŽĚƐ͕ǁŽƌŬƐ͕ĂŶĚŶŽŶͲĐŽŶƐƵůƟŶŐƐĞƌǀŝĐĞƐƵŶĚĞƌ/ZůŽĂŶƐĂŶĚ/ ĐƌĞĚŝƚƐĂŶĚŐƌĂŶƚƐďLJtŽƌůĚĂŶŬŽƌƌŽǁĞƌƐ͘tĂƐŚŝŶŐƚŽŶ͕ϮϬϭϭ ϭϭ͘ 'ůŽďĂů&ƵŶĚƚŽ&ŝŐŚƚ/^͕dƵďĞƌĐƵůŽƐŝƐĂŶĚDĂůĂƌŝĂ͘'ƵŝĚĞƚŽ'ůŽďĂů&ƵŶĚƉŽůŝĐŝĞƐŽŶƉƌŽĐƵƌĞŵĞŶƚ ĂŶĚƐƵƉƉůLJŵĂŶĂŐĞŵĞŶƚŽĨŚĞĂůƚŚƉƌŽĚƵĐƚƐ͘'ĞŶĞǀĂ͕ϮϬϭϮ͘ ϭϮ͘ tŽƌůĚ ,ĞĂůƚŚ KƌŐĂŶŝnjĂƟŽŶͬ,ĞĂůƚŚ ĐƟŽŶ /ŶƚĞƌŶĂƟŽŶĂů͘ DĞĂƐƵƌŝŶŐ ŵĞĚŝĐŝŶĞ ƉƌŝĐĞƐ͕ ĂǀĂŝůĂďŝůŝƚLJ͕ ĂīŽƌĚĂďŝůŝƚLJĂŶĚƉƌŝĐĞĐŽŵƉŽŶĞŶƚƐ͘Ϯnd_{ĞĚŝƟŽŶ͘'ĞŶĞǀĂ͕ϮϬϬϴ͘ŚƩƉ͗ͬͬŚĂŝǁĞď͘ŽƌŐͬǁŚĂƚͲǁĞͲĚŽͬƉƌŝĐĞͲ} ĂǀĂŝůĂďŝůŝƚLJͲĂīŽƌĚĂďŝůŝƚLJͬ ϭϯ͘ DŝŶŝƐƚƌLJŽĨ,ĞĂůƚŚĂŶĚDŝŶŝƐƚƌLJŽĨ/ŶĚƵƐƚƌLJ͕&ĞĚĞƌĂůĞŵŽĐƌĂƟĐZĞƉƵďůŝĐŽĨƚŚŝŽƉŝĂ͘EĂƟŽŶĂůƐƚƌĂƚĞŐLJ ĂŶĚƉůĂŶŽĨĂĐƟŽŶĨŽƌƉŚĂƌŵĂĐĞƵƟĐĂůŵĂŶƵĨĂĐƚƵƌŝŶŐĚĞǀĞůŽƉŵĞŶƚŝŶƚŚŝŽƉŝĂ;ϮϬϭϱͲϮϬϮϱͿ͘ĞǀĞůŽƉŝŶŐ ƚŚĞƉŚĂƌŵĂĐĞƵƟĐĂůŝŶĚƵƐƚƌLJĂŶĚŝŵƉƌŽǀŝŶŐĂĐĐĞƐƐ͘:ƵůLJϮϬϭϱ͘ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬƉŚŝͬƉƵďůŝĐĂƟŽŶƐͬ ƚŚŝŽƉŝĂͺƐƚƌĂƚĞŐLJͺůŽĐĂůͺƉŽĚƵĐƟŽŶ͘ƉĚĨ