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ACCESSIBILITY TO MEDICINES FOR MAJOR NON-COMMUNICABLE DISEASES IN JORDAN – 2018 (INTERNAL BRIEFING DOCUMENT)Karir, Veena; Bygrave, Helen; Cepuch, Christa; Davis, Brett; Elder, Greg; Jobanputra, Kiran; Reddy, Amulya; MSF (2018)This is a summary of work undertaken between March 2018 and May 2018 in order to increase understanding of accessibility to medicines for major non-communicable diseases (NCDs) among Jordanians and urban Syrian refugees. It includes multiple facets of accessibility - affordability, availability, price determinants, government and out-of-pocket expenditures, the pharmaceutical and health sectors, and prescriber and consumer behaviours. Overall accessibility to medicines in Jordan for the NCDs studied here is relatively high. However, a minority of the population does not access treatment, mainly due to affordability (predominantly provider costs, but also medicines and transportation costs); these factors are most likely linked to capacity to pay given that expenditures exceed income among Jordanians and urban refugees, the majority of whom report debt. It is imperative to understand that price of medicines cannot be examined in isolation but needs to be considered in relation to capacity to pay, as even very low-priced generic medicines remain out of reach for lower-income households. All World Health Organization (WHO) essential drugs (oral plus insulin) for the NCDs studied here were registered by the Jordan Food and Drug Administration, and procured by the government for the public sector. Based on the literature, public sector availability of medicines for NCDs is generally limited among lower income countries investigated. However, only a minority of urban Syrian refugees reported unavailability of medicines in the Jordanian public sector. From the literature, private sector NCD medication availability is higher and close to 80% among higher income countries and in urban settings; it is also higher in lower income countries, for medicines to treat cardiovascular disease. These findings should hold true for Jordan. Jordan has sufficient healthcare resources. Government expenditure on health exceeds that of many Middle East North Africa (MENA) countries of the same income group, while the population has lower out-of-pocket expenditure compared to the same group of countries. Government purchases of medicines (availability) are likely sufficient for cardiovascular disease, hypertension and non-insulin-dependent diabetes if 65% or fewer of the affected population access the public sector. Most medicines used to treat major NCDs are procured at competitive prices (comparable to the international reference price) by the Jordanian government. Public tendering as well as pricing of medicines is transparent in Jordan. In the private sector, prices are essentially fixed by law, but despite this pricing is heavily influenced by the pharmaceutical sector, whose priorities lie with profitability and in general, the predominant export market. The majority of medicines for major NCDs were determined to be affordable (less than one day’s wage to purchase a 30-day supply) in the public sector, even when multiple drugs were prescribed for hypertension, cardiovascular disease and/or diabetes. Affordability in the private sector is predominantly the case for medicines for hypertension, cardiovascular disease and oral medicines for diabetes; notable exceptions include insulin, fixed-dose combination (FDC) inhalers and statins. Across both sectors, higher costs can be attributable to prescriber practices, consumer preferences and predominance of brand drugs, especially for insulin and FDC inhalers. Risk factors for NCDs among Jordanians and Syrians surpass global averages, driving disability and death. While affordability comes through as the main obstacle in accessing health care, annually Jordanians are spending more on tobacco than medical expenses. Considerations for humanitarian and other implementing organizations: - Prior to engaging in NCD interventions, evaluation of the existing health system is key to determining how to plan (if at all), where along the continuum of NCD care the focus of the response should be and whom to target. - Programming details and operational costs need to factor procurement options, as there may be governmental requirements for local and/or international sourcing. - Prevention possibilities should be reviewed in relation to NCDs given known impact on reducing death and disability.