In middle-income countries

Warren Kaplan argues that we should expect hybrid structures to appear in the pharmaceutical industries of the important middle-income producers of generic medicines (e.g., India). Notwithstanding the possible effect of these structures on pharmaceutical innovation in middle-income countries, this restructuring is likely to have important consequences for access to affordable medicines. The effect of these hybrid structures on real pharmaceutical innovation in the established pharmaceutical industry and in the newer public-private initiatives is still unclear. 

The US 1/day rate was found by Chen and Ravallion to be representative of the poverty lines found among low-income countries in the first years such calculations of global poverty were done. These calculations attempt to express in a common currency the purchasing power of varied domestic currencies such purchasing power parity comparisons, while usefiJ, are inexact. US 2/day is more representative of poverty in middle-income countries. 

A more recent and selective comparison of evidence (figure 4.3) confirms that in middle-income countries at least, programs can, but are not guaranteed to, have errors of inclusion as low as those found in some programs in countries such as the United States. Box 4.1 discusses targeting goals in much poorer countries. 

Safety net systems in middle-income countries may aspire to cover all target groups and motivations for safety nets, although they tend to focus on helping the chronically poor. Individual programs may be quite sophisticated, but innovations may not have spread to all programs in the country that might benefit from them. 

In effect, of course, such diseases are the ones primarily prevalent in low-income countries. Figure 4.1 shows diseases according to total disability-adjusted life years (DALYs) lost to each disease or condition. (A DALY is a standardized measure of health outcomes.) Some diseases are grouped together for convenience. The vertical axis shows the weight of each disease in low- and lower-middle-income countries, relative to its weight in high-and upper-middle-income countries. A disease responsible for 6% of lost... 

Data from The Cochrane Library in 2004 show that there are more than 11,500 people working within The Cochrane Collaboration in 91 countries, half of whom are authors of Cochrane Reviews. The number of people has increased by about 20% every year for the last five years. The increase in the number of contributors from low, lower-middle and upper-middle income countries has been even greater, to more than 1000 (9.3%) in 2004 - up by 42% since 2003, and by 248% since 2000. See Reference Centres by country (www.cochrane.org/contact/country.htm) and a world map showing the locations of the Cochrane Centres (www.cochrane.org//contact/entities.htm centres). 

Health reforms. In many low-income and middle-income countries, health sector reforms have led to insufficient public funding for health. 

Medicines financing. In many high-income countries, over 70% of medicines are publicly funded, whereas in low- and middle-income countries public medicines expenditures does not cover the basic medicines needs of the majority of the population. In these countries, 50-90% of medicines are paid for by patients themselves. 

Globalization. Global trade agreements can have a negative impact on access to newer essential medicines in low- and middle-income countries. Access to health care and therefore to essential... 

Sustainable financing for essential medicines must be viewed in the context of overall health care financing. Most low- and-middle income countries rely on a diverse set of health and medicines financing mechanisms which can contribute in the payment of medicines. Nevertheless there are still opportunities in many low and middle income countries for both better and more public funding on health and essential medicines. 

Donor funding for and donations of medicines can have an impact on health in low- and middle-income countries in the short term. In the medium term these donations should be targeted at specific diseases and planned as additional supplies integrated into the national medicines supply system. But in the long term, self-sufficiency is the only viable means to tackle increasing disease burdens. 

International Union Against Tuberculosis and Lung Disease (lUALTD). Promoting lung health in low- and middle-income countries [Online]. [cited 2007 October 7]. Available from URL http //www.iuatld.org/pdf/en/flchesasthma.pdf... 

Krug, E. G. Firearm-Related Deaths in the United States and 35 Other High- and Upper-Middle-Income Countries.The Journal of the American Medical Association, vol. 280, August 5, 1998, p. 401. Reports that the 49th World Health Assembly has declared violence a worldwide public health problem. Using data provided by health officials, a study concludes that firearms death rates are much higher in the United States and that types of death (murder or suicide) as well as rates vary with national income. 

Communicable diseases continue to kill around 14 million people each year, mostly in the developing world. Infectious and parasitic diseases account for a quarter of the disease burden in low- and middle-income countries, compared to only 3 per cent in high-income countries (WHO 1999). According to the World Bank, eliminating communicable diseases would almost completely level the mortality gap between the richest 20 per cent of the world population and the poorest 20 per cent (Gwatkin and Guillot 2000). 

In a second, more recent study, published in Health Affairs in 2004, Attaran examines the extent to which "essential medications" are patented in low-income and middle-income countries more generally. The findings are once again surprising ... 

Seiter, A. 2005. Pharmaceuticals Drug Regulation in Low and Middle Income Countries. Health, Nutrition and Population Brief No. 4. Washington World Bank. 

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