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2.5.3.1 China

China has at least 1,3 billion population with an average health expenditure of 5,6 percent with drug expenditures comprising up to 40 percent of total health expenditures ranking amongst the highest proportions in the world, however, the country experienced challenges with essential medicines provisioning.

Yang, Dib, Zhu, Gang and Zhang (2010:224) reported that the availability of low price generic medicine in the Hubei province was found to be 38, 9 percent in the public sector and 44, 4 percent in the private sector. Further, a field survey conducted in Shandong and Gansu provinces in 2007 revealed that the median availability of surveyed medicines in hospital pharmacies ranged from 19 to 69 percent. Moreover, the Chinese people have suffered from inaccessible and unaffordable health services for decades. By the end of 2012, there were still eighty thousand five hundred and twelve people, comprising approximately 6 percent of the population, who lacked access to health services (Li, Li, Zhu Fu, Xu, Wei & Chu 2015:345).

Another survey conducted in 2006 in Shanghai, China, revealed that the overall availability of medicine was poor in both the public and private sectors. Generic medicine was more readily available in the public sector than the private sector. The average availability in the public sector was 13, 3 percent for the innovator (non-generic expensive) brand and 33,3 percent for the lower priced generics respectively, whilst in private pharmacies the average availability for innovator brands was 10 percent and 15 percent for lower priced generics. The factors reported to contribute mainly to the poor provisioning include prescribers’ preference of branded drugs rather than generic medicines in the public sector as evidenced by doctors not prescribing medicines on the essential lists resulting in essential medicines not being ordered for utilisation in public health facilities (Lu 2006:35).

In 2009 the government of China invested in large-scale health care reform to achieve universal health care coverage. One of the major reform components focuses on improving access to essential medicines to reduce high out–of–pocket medicines

spending. The reform policies were comprehensive, and included systematic selection of essential medicines to improve availability, centralised procurement and tendering at provincial levels, pricing policies, provision of essential medicines at cost in primary level facilities, and stronger quality and safety standards. While challenges remain, China's system sets an example of a comprehensive approach that other countries could emulate in reforming their health care systems and achieving universal coverage (Barber, Huang, Santoso, Laing, Paris & Wu 2013:1).

2.5.3.2 Pakistan

With a population of 182 million and health expenditure of 2,8 percent of the country’s gross domestic product (WHO 2015). The country is affected in the provision of essential medicines by the lack of standard procurement systems and effective use and maintenance of health technologies for the primary health care network posing serious limitations to the delivery of quality care to an extent that the insufficient availability of medicines has detrimentally affected the use of public health services where a very limited proportion of public sector facilities had an uninterrupted flow of essential medicines.

According to the study conducted in 2010, there was insufficient availability of medicines which affected the use of public health facilities as there were few health facilities that had uninterrupted essential medicine supply. The author proposed that to enhance access to life-saving primary health care services, essential medicines should be procured in sufficient quantities along with improved efforts to reduce stock outs caused by improper procurement and transport, storage and management deficiencies (Sabih, Bile, Buehler, Hafeez, Nishtar & Siddiqi 2010:142).

Poor availability and erratic supply of medicines in the Pakistan government sector are rooted in several factors such as inadequate management to address the local needs, poor distribution at the level of local health facilities, corruption at the level of distributers and suppliers and inefficiencies in the supply and distribution chain and insufficient availability of medicines in appropriate dosage forms for children as found in other studies (Shafiq, Shaik & Kumar 2011:136).

2.5.3.3 Philippines

With a population of 98 million and health expenditure of 4,4 percent of the GDP (WHO 2015). In this country a 2009 study conducted using WHO methodology indicated that availability of essential medicines in the public health facilities was 53,3 percent. In the private sector it was at 100 percent, and in central district warehouses supplying the public sector it was 33,3 percent. The stock out duration for the public facilities was an average of 24, 9 days and 43, 8 days in the central districts warehouses respectively. The factors contributing to the insufficient provisioning were poor provisioning systems including non-centralisation of procurement from the district warehouses, as facilities could still bypass the warehouses to obtain medicines elsewhere, as well as high medicine prices in the country (Batangan & Juban 2009:34).

2.5.3.4 Malaysia

This country has at least 29 million populations and spends 4 percent of the GDP on health (WHO 2015). According to Babar, Ibrahim, Sing and Bukhari (2005:17), in the Malaysian public sector only 25 percent of the generic medicines were available in the 20 facilities surveyed. The factors contributing to the poor provisioning and low availability were under-regulation of medicine prices, uncapped mark-ups by health practitioners and poor monitoring for the provision and procurement of medicines on the National Essential Drug List. The pharmacist’s role in ensuring the availability of medicine was also limited as medicine was freely available in private doctors’ consulting rooms. However, stricter measures were imposed on medicine control and issuing by pharmacists. The country also did not have a national medicine pricing policy. The recommendations included that government should control mark-ups on generic brands and ensure that medicines on the National Essential Drug List are available in the public sector.

In summary within this region, the factors contributing to poor provisioning and low availability of essential medicines were:

 Poor quality of medicine in circulation as the strength of medicine available differed from the recommended strength in the WHO survey manual.

 Lack of supply from the manufacturers due to low government prices.  Irrational use of medicine due to financial incentives.

 That profit driven prescribing physicians were prescribing more expensive medicines.

 The hospital centred issuing of medicine which led to low medicine availability in private pharmacies as patients were encouraged to obtain medication in hospital rather than in private pharmacies.

 That the policy on global budget control on pharmaceutical expenditure limited the procurement of innovator non-generic medicines.