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Too Costly & Too Scarce

Ewen, M.A.

2016

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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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countries. Several studies included assessments of the availability of medicines for acute ǀĞƌƐƵƐĐŚƌŽŶŝĐĐŽŶĚŝƟŽŶƐ;ϴͿ, cardiovascular medicines in developing countries ;ϵͿ͕ĂŶƟͲ ĞƉŝůĞƉƟĐƐŝŶĂŵďŝĂ;ϭϬͿĂŶĚŝŶ>ĂŽƐ;ϭϭͿ͕ĂŶĚĂŶƟͲĚŝĂďĞƟĐŵĞĚŝĐŝŶĞƐŝŶƚŚĞWŚŝůŝƉƉŝŶĞƐ͘

;ϭϮͿ͘^ŝŵŝůĂƌĐŽŶĐůƵƐŝŽŶƐǁĞƌĞĚƌĂǁŶŝŶƚŚĞƐĞƐƚƵĚŝĞƐ͕ŶĂŵĞůLJƚŚĂƚƚŚĞŽǀĞƌĂůůĂǀĂŝůĂďŝůŝƚLJ ŽĨ ǁŝĚĞůLJ ƵƐĞĚ ŵĞĚŝĐŝŶĞƐ ŝŶĐůƵĚŝŶŐ ŐĞŶĞƌŝĐƐ ǁĂƐ ƐƵďŽƉƟŵĂů͕ ƉĂƌƟĐƵůĂƌůLJ ŝŶ ƚŚĞ ƉƵďůŝĐ ƐĞĐƚŽƌ͘ /Ŷ ĐŽŶƚƌĂƐƚ͕ ƐŽŵĞ ƐƚƵĚŝĞƐ ƐŚŽǁĞĚ ĂĚĞƋƵĂƚĞ ŵĞĚŝĐŝŶĞƐ͛ ĂǀĂŝůĂďŝůŝƚLJ͘ ^ƚƵĚŝĞƐ ŽŶ standardized lists of commonly used medicines in Sudan ;ϭϯͿĂŶĚƵƌŬŝŶĂ&ĂƐŽ;ϭϰͿƐŚŽǁĞĚ ĂƐĂƟƐĨĂĐƚŽƌLJůĞǀĞůŽĨŶĞĂƌůLJϴϬйĂǀĂŝůĂďŝůŝƚLJŽĨƚŚĞƐƵƌǀĞLJĞĚŵĞĚŝĐŝŶĞƐ͘

EŽŶĞŽĨƚŚĞƐĞƐƚƵĚŝĞƐĨŽĐƵƐĞĚĞdžĐůƵƐŝǀĞůLJŽŶĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐ͘dŚĞĨŽůůŽǁŝŶŐƐƚƵĚŝĞƐ ŵĂLJƉƌŽǀŝĚĞĂŶŝŶƐŝŐŚƚŽŶƚŚĞĞdžƚĞŶƚŽĨĂǀĂŝůĂďŝůŝƚLJŽĨŵĞĚŝĐŝŶĞƐŝŶĐůƵĚĞĚŝŶŶĂƟŽŶĂůD>Ɛ ŝŶĚŝīĞƌĞŶƚĐŽƵŶƚƌŝĞƐ͘ďŽǀĞϳϱйĂǀĞƌĂŐĞĂǀĂŝůĂďŝůŝƚLJŽĨŐĞŶĞƌŝĐŵĞĚŝĐŝŶĞƐǁĂƐƌĞƉŽƌƚĞĚ ŝŶĂŶĂƟŽŶĂůƐƵƌǀĞLJŽĨĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐŝŶƚŚĞƉƌŝǀĂƚĞƐĞĐƚŽƌŝŶ^ƌŝ>ĂŶŬĂ;ϭϱͿ and in the public sector and popular pharmacies in Brazil ;ϭϲͿ͕ĂƐǁĞůůĂƐŝŶƉƌŽǀŝŶĐŝĂůƐƵƌǀĞLJƐŽŶ ĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐŝŶƚŚŝŽƉŝĂ;ϭϳͿ͕ƉƌŝŵĂƌLJŚĞĂůƚŚĐĂƌĞĐĞŶƚĞƌƐ͛ĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐŝŶ /ŶĚŝĂ;ϭϴͿ͕ĂŶĚƚŚĞĐŚŝůĚƌĞŶ͛ƐŶĂƟŽŶĂůƌƵƌĂůŚĞĂůƚŚŵŝƐƐŝŽŶůŝƐƚŝŶƚŚĞƉƵďůŝĐƐĞĐƚŽƌŝŶ/ŶĚŝĂ ;ϭϵͿ͘ŽŶǀĞƌƐĞůLJ͕ĂŶĂƟŽŶĂůƐƚƵĚLJŽŶƚŚĞĂǀĂŝůĂďŝůŝƚLJŽĨƉĞĚŝĂƚƌŝĐĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐŝŶ^ƌŝ >ĂŶŬĂ͛ƐƉƵďůŝĐƐĞĐƚŽƌ;ϮϬͿĂƐǁĞůůĂƐƉƌŽǀŝŶĐŝĂůƐƵƌǀĞLJƐŽŶŶĂƟŽŶĂůĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐŝŶ China ;Ϯϭ͕ϮϮͿĂůůƉŽŝŶƚĞĚƚŽŝŶĂĚĞƋƵĂƚĞĂǀĂŝůĂďŝůŝƚLJŽĨƚŚĞĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐƐƚƵĚŝĞĚ͘ /ŶǀŝĞǁŽĨƚŚĞůŝŵŝƚĞĚŶƵŵďĞƌŽĨƐƚƵĚŝĞƐƚŽĚĂƚĞ͕ŶŽĞdžƚĞŶƐŝǀĞĐŽŶĐůƵƐŝŽŶƐĐĂŶďĞĚƌĂǁŶ ŽŶ ǁŚĞƚŚĞƌ ĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ĂƌĞ ĂĚĞƋƵĂƚĞůLJ ĂǀĂŝůĂďůĞ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ŐůŽďĂů ĞīŽƌƚƐ ƚŽ ŝŵƉůĞŵĞŶƚ ĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ƉŽůŝĐŝĞƐ͘ dŚĞƌĞĨŽƌĞ͕ ƚŚŝƐ ŝŶƚĞƌŶĂƟŽŶĂů ƐƚƵĚLJ ǁĂƐ ƵŶĚĞƌƚĂŬĞŶ ƚŽ ĂƐƐĞƐƐ ĚŝīĞƌĞŶĐĞƐ ŝŶ ƚŚĞ ĂǀĂŝůĂďŝůŝƚLJ ŽĨ ĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ĐŽŵƉĂƌĞĚ ƚŽ ŵĞĚŝĐŝŶĞƐ ǁŚŝĐŚ ĂƌĞ ŶŽƚ ŽŶ D>Ɛ ;ŚĞƌĞĂŌĞƌ ĐĂůůĞĚ ͞ŶŽŶͲĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ͟Ϳ ŝŶ ďŽƚŚ public and private sectors.

Dd,K^

ĂƚĂƐŽƵƌĐĞ

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ĐŽŶĚƵĐƚĞĚŝŶĐŽŵƉůŝĂŶĐĞǁŝƚŚĂƐƚĂŶĚĂƌĚŵĞƚŚŽĚŽůŽŐLJĚĞǀĞůŽƉĞĚďLJt,Kͬ,/;Ϯϰ͕ϮϱͿ. The survey medicines comprised a core list and a supplementary list of medicines. The ĐŽƌĞůŝƐƚǁĂƐƐĞůĞĐƚĞĚĨƌŽŵŵĞĚŝĐŝŶĞƐŝŶĚŝĐĂƚĞĚĨŽƌĐŽŵŵŽŶĐŚƌŽŶŝĐŽƌĂĐƵƚĞĐŽŶĚŝƟŽŶƐŝŶ global and regional scales. The supplementary list included medicines selected at country ůĞǀĞůďĂƐĞĚŽŶƚŚĞŝƌůŽĐĂůŝŵƉŽƌƚĂŶĐĞĨŽƌŶĂƟŽŶĂůŚĞĂůƚŚĐĂƌĞƐLJƐƚĞŵƐ͘WƌĂĐƟĐĂůĚĞƚĂŝůƐ ŽĨƚŚĞƐƵƌǀĞLJƐĂƐǁĞůůĂƐƚŚĞǀĂůŝĚĂƟŽŶŵĞƚŚŽĚŚĂǀĞďĞĞŶĞdžƉůĂŝŶĞĚĞůƐĞǁŚĞƌĞ;ϳ͕Ϯϯ͕ϮϲͿ. ƐĂƐĞĐŽŶĚƐƚĞƉ͕ĂůůŶĂƟŽŶĂůD>ƐǁĞƌĞŽďƚĂŝŶĞĚĨƌŽŵƚŚĞt,KĚĂƚĂďĂƐĞŽĨĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞůŝƐƚƐĂŶĚĨŽƌŵƵůĂƌŝĞƐǁŚŝĐŚŝƐĨƌĞĞůLJĂĐĐĞƐƐŝďůĞŽŶƚŚĞǁĞď;ϮϳͿ. ^ƚƵĚLJŝŶĐůƵƐŝŽŶ ůů ƐƵƌǀĞLJƐ ŝŶĐůƵĚĞĚ ŝŶ ƚŚĞ t,Kͬ,/ ĚĂƚĂďĂƐĞ ŽŶ ϭϱ Ɖƌŝů ϮϬϭϮ ǁĞƌĞ ŝŶĐůƵĚĞĚ ŝŶ ŽƵƌ ƐƚƵĚLJĞdžĐĞƉƚ;ĂͿƚŚŽƐĞĨŽƌǁŚŝĐŚƚŚĞŶĂƟŽŶĂůD>͕ĐƵƌƌĞŶƚĂƚƚŚĞƟŵĞŽĨƚŚĞƐƵƌǀĞLJ͕ǁĂƐ ŶŽƚĂǀĂŝůĂďůĞ͕ĂŶĚ;ďͿĞŝŐŚƚƉŝůŽƚƐƵƌǀĞLJƐǁŚĞƌĞĂǀĂŝůĂďŝůŝƚLJǁĂƐĂƐƐĞƐƐĞĚƵƐŝŶŐĂĚŝīĞƌĞŶƚ ŵĞƚŚŽĚŽůŽŐLJ͘tŚĞƌĞŵƵůƟƉůĞƐƵƌǀĞLJƐǁĞƌĞĐŽŶĚƵĐƚĞĚŝŶĂĐŽƵŶƚƌLJ͕ĂǀĞƌĂŐĞĂǀĂŝůĂďŝůŝƚLJ ǁĂƐĐĂůĐƵůĂƚĞĚǁŝƚŚŽƵƚǁĞŝŐŚƟŶŐ͘dĂďůĞϭůŝƐƚƐƚŚĞϮϯĐŽƵŶƚƌŝĞƐ;ϮϴƐƵƌǀĞLJƐͿŝŶĐůƵĚĞĚŝŶ the study. ĂƚĂĂŶĂůLJƐŝƐ ĂƚĂ ǁĞƌĞ ĂŶĂůLJnjĞĚ Ăƚ Ă ŐůŽďĂů ƐĐĂůĞ ĮƌƐƚ͘ WŽŽůĞĚ ĚĂƚĂ ŽĨ ƚŚĞ ƐƚƵĚŝĞĚ ŵĞĚŝĐŝŶĞƐ ǁĞƌĞ ĂƐƐŝŐŶĞĚ ƚŽ ĞŝƚŚĞƌ ĞƐƐĞŶƟĂů Žƌ ŶŽŶͲĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ͕ ďĂƐĞĚ ŽŶ ƚŚĞ ŶĂƟŽŶĂů D> Ăƚ ƚŚĞƟŵĞŽĨƚŚĞƐƵƌǀĞLJ͘ǀĂŝůĂďŝůŝƚLJǁĂƐĐĂůĐƵůĂƚĞĚĂƐƚŚĞƉĞƌĐĞŶƚĂŐĞŽĨŵĞĚŝĐŝŶĞŽƵƚůĞƚƐ ƐƵƌǀĞLJĞĚǁŚĞƌĞƚŚĞŵĞĚŝĐŝŶĞǁĂƐĂǀĂŝůĂďůĞŽŶƚŚĞĚĂLJŽĨĚĂƚĂĐŽůůĞĐƟŽŶ͘/ŶĂĚĚŝƟŽŶƚŽ studying the availability of originator brands and generic equivalents, the availability of ĂŶLJƉƌŽĚƵĐƚƚLJƉĞ;ŽƌŝŐŝŶĂƚŽƌďƌĂŶĚŽƌŐĞŶĞƌŝĐĐŽŵďŝŶĞĚ͕ƐĞĞdĂďůĞϮĨŽƌĚĞĮŶŝƟŽŶƐͿǁĂƐ assessed to determine the overall availability of each medicine.

dŚĞŵĞĚŝĂŶĂǀĂŝůĂďŝůŝƚLJŽĨŽƌŝŐŝŶĂƚŽƌďƌĂŶĚƐ͕ŐĞŶĞƌŝĐƐĂŶĚĂŶLJƉƌŽĚƵĐƚƚLJƉĞǁĂƐĐĂůĐƵůĂƚĞĚ ĂŶĚĐŽŵƉĂƌĞĚĨŽƌĞƐƐĞŶƟĂůĂŶĚŶŽŶͲĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐ͕ĂĐƌŽƐƐĂůůƐĞĐƚŽƌƐĂŶĚŝŶĚŝǀŝĚƵĂů ƐĞĐƚŽƌƐ;ƉƵďůŝĐ͕ƉƌŝǀĂƚĞͿ͘

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5

dĂ

ďůĞϭ͗

Coun

tries and sur

ϵϮ EŽŶͲƉĂƌĂŵĞƚƌŝĐƌĂŶŬƚĞƐƚƐƉĞƌĨŽƌŵĞĚǁĞƌĞ;ϭͿƚŚĞDĂŶŶͲtŚŝƚŶĞLJhƚĞƐƚƚŽĐŽŵƉĂƌĞƚŚĞ ĂǀĂŝůĂďŝůŝƚLJ ŽĨ ĞƐƐĞŶƟĂů ǀĞƌƐƵƐ ŶŽŶͲĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ǁŚĞŶ ŚŽŵŽŐĞŶĞŝƚLJ ŽĨ ǀĂƌŝĂŶĐĞƐ ǁĂƐĞƐƚĂďůŝƐŚĞĚ͕;ϮͿƚŚĞDŽŽĚƐŵĞĚŝĂŶƚĞƐƚƚŽĐŽŵƉĂƌĞĂǀĂŝůĂďŝůŝƚLJŽĨĞƐƐĞŶƟĂůǀĞƌƐƵƐŶŽŶͲ ĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐǁŚĞŶŚŽŵŽŐĞŶĞŝƚLJŽĨǀĂƌŝĂŶĐĞƐǁĂƐŶŽƚĂƐƐƵŵĞĚ͕ĂŶĚ;ϯͿĂ<ƌƵƐŬĂůͲ tĂůůŝƐ ŽŶĞͲǁĂLJ ĂŶĂůLJƐŝƐ ŽĨ ǀĂƌŝĂŶĐĞ ďLJ ƌĂŶŬƐ ĨŽƌ ĐŽŵƉĂƌŝŶŐ ĂĐƌŽƐƐ tŽƌůĚ ĂŶŬ ŝŶĐŽŵĞ ŐƌŽƵƉƐŝŶƚĞƌŵƐŽĨƚŚĞĂǀĂŝůĂďŝůŝƚLJŽĨĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐ͘dŽĂƐƐĞƐƐŝĨƚŚĞĂǀĂŝůĂďŝůŝƚLJŐĂƉ ŽĨ ĞƐƐĞŶƟĂů ĂŶĚ ŶŽŶͲĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ŝƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ƚŚĞ 'ŝŶŝ ĐŽĞĸĐŝĞŶƚ͕ ůŝŶĞĂƌ ƌĞŐƌĞƐƐŝŽŶĂŶĂůLJƐŝƐǁĂƐĞdžĂŵŝŶĞĚ͘ƉсǀĂůƵĞƐŵĂůůĞƌƚŚĂŶϬ͘ϬϱǁĂƐĐŽŶƐŝĚĞƌĞĚƐŝŐŶŝĮĐĂŶƚ for all the tests.

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ŵĞĚŝĐŝŶĞƐ ǁĂƐ Ϯϳ͘ϯй͘ dŚŝƐ ĚŝīĞƌĞŶĐĞ ŝŶ ĂǀĂŝůĂďŝůŝƚLJ ǁĂƐ ĚƌŝǀĞŶ ďLJ ŐĞŶĞƌŝĐ ŵĞĚŝĐŝŶĞƐ͖ ƚŚĞŵĞĚŝĂŶĂǀĂŝůĂďŝůŝƚLJŽĨŐĞŶĞƌŝĐĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐǁĂƐϱϯ͘ϯйǀĞƌƐƵƐϭϵ͘ϮйĨŽƌŶŽŶͲ ĞƐƐĞŶƟĂůŐĞŶĞƌŝĐƐ͘dŚĞŽǀĞƌĂůůŵĞĚŝĂŶĂǀĂŝůĂďŝůŝƚLJŽĨŽƌŝŐŝŶĂƚŽƌďƌĂŶĚƐǁĂƐϬй͕ǁŝƚŚŶŽ ƐŝŐŶŝĮĐĂŶƚ ĚŝīĞƌĞŶĐĞ ďĞƚǁĞĞŶ ĞƐƐĞŶƟĂů ;/YZ Ϭйശϭϴ͘ϰйͿ ĂŶĚ ŶŽŶͲĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ;/YZϬйശϮϭ͘ϭйͿ;ƉсϬ͘ϱϳϵͿ͘^ŝŵŝůĂƌƉĂƩĞƌŶƐǁĞƌĞŽďƐĞƌǀĞĚŝŶĞĂĐŚƐĞĐƚŽƌ͘

dĂďůĞϯ͗Median availability of surveyed medicines

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ϵϵ

5

ƌĞĐĞŶƚ LJĞĂƌƐ ŝŶƚĞƌŶĂƟŽŶĂů ĚŽŶŽƌƐ ŚĂǀĞ ĨƵŶĚĞĚ ƉƌŽŐƌĂŵƐ ǁŚŝĐŚ ŚĂǀĞ ƐĂǀĞĚ ƚŚĞ ůŝǀĞƐ ŽĨ ŵŝůůŝŽŶƐ ŽĨ ƉĞŽƉůĞ ŝŶ >D/Ɛ;ϯϲͿ͘ ^ƵĐŚ ƉƌŽŐƌĂŵƐ ĐĂŶ ďĞŶĞĮƚ ƐŽĐŝĞƟĞƐ ŵŽƐƚ ŝĨ ƚŚĞLJ ĂƌĞ ĂůŝŐŶĞĚ ǁŝƚŚ ŶĂƟŽŶĂů ŚĞĂůƚŚ ĐĂƌĞ ƉƌŝŽƌŝƟĞƐ͘ /ƚ ŚĂƐ ďĞĞŶ ĂƌŐƵĞĚ ƚŚĂƚ ĚŽŶŽƌƐ ĚŽ ŶŽƚ ŶĞĐĞƐƐĂƌŝůLJ ĨƵŶĚ ƚŚĞ ŵŽƐƚ ƌĞůĞǀĂŶƚ ŝŶƚĞƌǀĞŶƟŽŶƐ;ϯϳͿ͘ WƌŽĐƵƌĞŵĞŶƚ ŶĞĐĞƐƐŝƟĞƐ ŽĨ ĞĂĐŚ ŝŶĚŝǀŝĚƵĂůĐŽƵŶƚƌLJŵŝŐŚƚďĞďĞƐƚƌĞŇĞĐƚĞĚŝŶŝƚƐĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐůŝƐƚ͘ ŶŚĂŶĐŝŶŐ ůŽĐĂů ŵĂŶƵĨĂĐƚƵƌŝŶŐ ĐĂƉĂĐŝƟĞƐ͕ ĂŶĚ ƵƐŝŶŐ ŇĞdžŝďŝůŝƟĞƐ ŝŶ ŝŶƚĞƌŶĂƟŽŶĂů ƚƌĂĚĞ ĂŐƌĞĞŵĞŶƚƐƐƵĐŚĂƐdZ/W^ĨŽƌƉĂƚĞŶƚĞĚƉƌŽĚƵĐƚƐ͕ƚŽŝŵƉƌŽǀĞƚŚĞĂǀĂŝůĂďŝůŝƚLJŽĨĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ Ăƚ ŵŽƌĞ ĂīŽƌĚĂďůĞ ƉƌŝĐĞƐ ƐŚŽƵůĚ ŶŽƚ ďĞ ŝŐŶŽƌĞĚ ďLJ ƚŚĞ ĂƵƚŚŽƌŝƟĞƐ͘ ŚĞŶ Ğƚ Ăů͘ ĚĞƐĐƌŝďĞĚ Ă ĐĂƐĞ ŝŶ ǁŚŝĐŚ ůŽĐĂů ŵĂŶƵĨĂĐƚƵƌĞƌƐ ĚŝĚ ŶŽƚ ƉƌŽĚƵĐĞ ŵŽƌĞ ƚŚĂŶ ϲϬй ŽĨ ƚŚĞ ĞƐƐĞŶƟĂů ŵĞĚŝĐŝŶĞƐ ƚŚĞLJ ǁĞƌĞ ůŝĐĞŶƐĞĚ ƚŽ ƐƵƉƉůLJ;ϮϭͿ͘ /ƚ ŚĂƐ ďĞĞŶ ƐƚĂƚĞĚ ƚŚĂƚ ůŽĐĂů ƉƌŽĚƵĐƟŽŶ ŚĂƐ ƚŚĞ ƉŽƚĞŶƟĂů ƚŽ ŝŵƉƌŽǀĞ ĂĐĐĞƐƐ ƚŽ ŵĞĚŝĐŝŶĞƐ ;ϯϴͿ͘ ,ŽǁĞǀĞƌ͕ ƚŚĞƌĞ ĂƌĞ ƐŽŵĞ ĚŽƵďƚƐ ƌĞŐĂƌĚŝŶŐ ƚŚĞ ĞdžŝƐƚĞŶĐĞ ŽĨ ĞŶŽƵŐŚ ĞŵƉŝƌŝĐĂů ƐƵƉƉŽƌƟǀĞ ĞǀŝĚĞŶĐĞ;ϯϵͿ. DĂĐŬĞLJĞƚĂů͘ĚŝĚŶŽƚĮŶĚǀĂůŝĚƉĂƚĞŶƚƐŽƌĚĂƚĂĞdžĐůƵƐŝǀŝƚLJƉƌŽǀŝƐŝŽŶƐĨŽƌƚŚĞŵĞĚŝĐŝŶĞƐ ůŝƐƚĞĚĨŽƌŶŽŶͲĐŽŵŵƵŶŝĐĂďůĞĚŝƐĞĂƐĞŝŶƚŚĞt,K͛ƐŵŽĚĞůůŝƐƚŽĨĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐ;ϰϬͿ. EĞǀĞƌƚŚĞůĞƐƐ͕ƉĂƚĞŶƚƉƌŽƚĞĐƟŽŶŝƐŶŽƚĂŶĞdžĐůƵƐŝŽŶĐƌŝƚĞƌŝĂĨŽƌƚŚĞƐĞůĞĐƟŽŶŽĨŵĞĚŝĐŝŶĞƐ ĨŽƌƚŚĞt,K͛ƐŵŽĚĞůůŝƐƚ͘ĞƐŝĚĞƐƉĂƚĞŶƚĞĚŵĞĚŝĐŝŶĞƐĐĂŶďĞĨŽƵŶĚŝŶŶĂƟŽŶĂůD>ƐĂƐ ǁĞůů͘ dŚĞ t,K ƉƌĞƋƵĂůŝĮĐĂƟŽŶ ƉƌŽŐƌĂŵ ĨŽƌ ŵĞĚŝĐŝŶĞƐ ;ŝŶĐůƵĚŝŶŐ ,/sͬ/^͕ ƚƵďĞƌĐƵůŽƐŝƐ͕ ĂŶƟŵĂůĂƌŝĂů ĂŶĚ ƌĞƉƌŽĚƵĐƟǀĞ ŵĞĚŝĐŝŶĞƐ ĂƐ ǁĞůů ĂƐ ǀĂĐĐŝŶĞƐͿ ŚĂƐ ƉƌŽǀŝĚĞĚ ĨƵƌƚŚĞƌ ŽƉƉŽƌƚƵŶŝƟĞƐ ĨŽƌ ƚŚĞ ƉƌŽĐƵƌĞŵĞŶƚ ŽĨ ƋƵĂůŝƚLJͲĂƐƐƵƌĞĚ ŵĞĚŝĐŝŶĞƐ ŝŶ Ă ĐŽŵƉĞƟƟǀĞ ĂŶĚ ĂīŽƌĚĂďůĞŵĂŶŶĞƌ;ϰϭ͕ϰϮͿ͘/ƚǁŽƵůĚďĞĨĂǀŽƌĂďůĞŝĨƐƵĐŚƉƌŽŐƌĂŵƐĐŽƵůĚďĞĞdžƚĞŶĚĞĚƚŽĂůů ƌĂŶŐĞƐŽĨĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐ͘