ACCESSIBILITY TO MEDICINES FOR MAJOR

NON-COMMUNICABLE DISEASES IN JORDAN

– 2018 (INTERNAL BRIEFING DOCUMENT)

Authors Karir, Veena; Bygrave, Helen; Cepuch, Christa; Davis, Brett;

Elder, Greg; Jobanputra, Kiran; Reddy, Amulya

Download date 09/10/2020 [Link]

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 ACCESSIBILITY TO MEDICINES FOR MAJOR NON-COMMUNICABLE DISEASES IN JORDAN – 2018

MSF INTERNAL BRIEFING DOCUMENT

Author: Veena Karir

Contributors: Helen Bygrave, Christa Cepuch, Brett Davis, Greg Elder, Kiran Jobanputra & Amulya Reddy

Acknowledgements: Ibrahim Khan, Intersectional Pharmacist, MENA, MSF for obtaining JFDA data & MSF
national staff, Jordan Mission

Analyses based on data from 2016 to 2018

Report finalized on 23 September 2019

1
Contents
1. EXECUTIVE SUMMARY .......................................................................................................3
2. INTRODUCTION.................................................................................................................4
3. METHODOLOGY ................................................................................................................4
4. BACKGROUND ..................................................................................................................4
4.1 Health sector ..............................................................................................................5
4.2 Pharmaceutical Sector ..................................................................................................6
5. KEY FINDINGS AND ANALYSES ..............................................................................................6
5.1 Availability .................................................................................................................6
5.1.1 Quantitative findings and analysis ......................................................................6
5.1.2 Evidence from the literature .............................................................................7
5.1.3 Government expenditure, fiscal space & out-of-pocket expenditure ............................9
5.1.4 Summary ................................................................................................... 10
5.2 Affordability ............................................................................................................. 11
5.2.1 Quantitative findings and analysis .................................................................... 11
[Link] Private sector pricing ....................................................................... 11
[Link] Public sector pricing ........................................................................ 12
[Link] Price determinants – competition, generics, packaging ............................. 12
[Link] Affordability per lowest wage metric ................................................... 13
[Link] Evidence from the literature .............................................................. 14
5.2.2 Prescriber and consumer (patient) behavior ........................................................ 15
5.2.3 Summary ................................................................................................... 16
5.3 ACCESSIBILITY ........................................................................................................... 17
5.3.1 Summary ................................................................................................... 17
6. PREVENTION ...................................................................................................................... 18
7. LIMITATIONS ..................................................................................................................... 19
8. CONCLUSIONS .................................................................................................................... 19
9. CONSIDERATIONS ............................................................................................................... 20
10. REFERENCES .................................................................................................................... 21
11. APPENDICES ..................................................................................................................... 25

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1. EXECUTIVE SUMMARY

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 behaviors.

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.

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2. INTRODUCTION

Médecins sans Frontières (MSF) has increased operations in the Middle East and North Africa (MENA) region in
recent years; this has required renewed focus on non-communicable diseases (NCDs) that are the predominant
causes of morbidity and mortality. As MSF will continue to operate or contemplate interventions in this context,
gaining institutional understanding on the how, when or not at all to do so as well as the implications of those
operational decisions becomes imperative. Current information gaps are in part due to the lack of:

- data on access to NCD medication in public and private sectors in countries where MSF has NCD focused
activities;
- transparency of cost of essential NCD medications through public and private systems;
- knowledge of pharma access initiatives and influencing of tendering and procurement processes for NCD
medication within the public sector.

This is a summary of work undertaken between March 2018 and May 2018, in collaboration with the MSF Access
Campaign (AC; created to support MSF Operations in improving access to essential medicines and diagnostics) and
with support from the Operational Centre Amsterdam (OCA) NCD advisor. The aim of this report is to describe
accessibility to treatment of NCDs amongst Jordanians and urban Syrian refugees and to explore the factors that
influence accessibility to include price determinants, government and out-of-pocket expenditures, the
pharmaceutical and health sectors as well as prescriber and consumer behaviors.

3. METHODOLOGY

Existing publicly available data sources from 2016 and 2017 for registered medicines, including pricing information,
in Jordan for the private and public sectors were obtained, and used to conduct quantitative analyses for availability
and affordability. Qualitative work included semi-structured interviews with local suppliers and manufacturers;
meetings and/or conversations with governmental officials, non-governmental organizations (NGOs), other local
organizations or consultants as well as regional and international MSF staff; and literature review and use of online
sources for gathering information pertaining to government and out-of-pocket expenditures, population and
country statistics, disease prevalence, etc.

To organize the work, a widely used definition (developed by Penchansky and Thomas in 1981) of access to
medicines, encompassing several dimensions including affordability, availability and accessibility, was adopted.1
NCDs for this analysis were defined as including: cardiovascular disease (CVD), hypertension, asthma, chronic
obstructive pulmonary disease (COPD), diabetes, epilepsy, psychiatric illnesses (depression, psychosis) and
hypothyroidism or hyperthyroidism.

4. BACKGROUND

Jordan, which has shifted between upper and lower middle-income country classifications in recent years (lower
2015-17; upper before 2015, and currently), has a total population of about 9.8 million.2,3 Syrian refugees contribute
an additional 660,000 to the population, with the majority living in urban areas.4 Deaths attributable to NCDs in 2016
ranked among the top three, including ischemic heart disease, CVD and diabetes; with hypertensive heart disease
ranking ninth and essentially all unchanged in ranking since 2005.5 Data from Syria is similar except conflict and terror
ranked number one in 2016 followed by ischemic heart disease, CVD (two and three), chronic kidney disease,
leukemia, COPD, and diabetes ranking fifth, seventh, ninth, and tenth; respectively.6 Apart from deaths attributable
to conflict and terror, which was ranked 145th in 2005, essentially all other rankings for Syria have remained the
same.

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In 2016 MSF OCA conducted a survey among 17,584 urban southern Syrian refugees in Irbid governorate, Jordan to
understand access to crucial health care services.7 Main findings revealed a population largely under 18 years of age
and, among the 2575 interviewed adults and guardians for 1570 children under 5 years of age, the majority had
required health care in the previous six months. Among all groups, the primary reason for seeking health care was
for communicable diseases, followed by joint pain and NCDs in adult men and NCDs and gynaecological care for
adult women. Unaffordability of provider costs was cited as the main reason for not seeking care among guardians
of 274 children and 530 adults, of which 61.7% and 66.7%, respectively did not seek it. Specifically, among 1243
interviewed adults with a NCD, 160 or 14.1% did not seek care citing provider costs; but the vast majority (831 of
873 individuals or 95.2%) who sought care, received it. Among those needing medication for a chronic condition,
23.1% (265 of 1146 individuals) reported an interruption of medication for greater than two weeks in the previous
six months; 63.4% (168 individuals) due to costs of the medications.

Over the past three years, the number of registered Syrian refugees has stayed relatively unchanged (660,315 as of
1 June 2017). Key findings from the CARE 2017 urban household survey among Syrian (the majority) and other
minority refugees as well as Jordanian citizens, identified cash, and cash for rent, as individuals’ primary need.8 Half
or more of individuals’ monthly expenditures were reported to be going towards rent. On average, Syrian refugees
spent 25% more than their income, while Jordanians almost tripled their expenditure gap from 56 Jordanian Dinars
(JD) in 2016 to 123.7 JD in 2017.

4.1 Health sector

Established in 2003, the Jordan Food and Drug Administration (JFDA), is charged with drug safety and efficacy as well
as food safety and quality. Governed by a board of directors and chaired by the Minister of Health, it is financially
and administratively independent. Since 2001, pricing of pharmaceuticals has been entrusted to the JFDA by law.9
In brief, innovator or brand drugs are priced by the lowest of four benchmarks (Appendix A, Box 1) while generics
are essentially priced at a ceiling of 80% of the brand product. Pricing is subject to reconsideration after 2 years for
innovator drugs and otherwise every 5 years upon renewal of registration if renewal is desired. However, a reduction
in price in the originator country (if used as the basis for the public price), must be communicated within 6 months
or penalties will ensue.9,10 For branded generics the first and second products are approved relatively quickly
(months); however for 3 rd or 4 th ones, there is little incentive for the JFDA to expedite approval given product
availability on the market; these later products will join the normal queue (1 to 2 years).11 Prices as determined by
the JFDA are publicly available and must be affixed to individual products in pharmacies.

Effective since 2004, the Joint Procurement Department (JPD) purchases drugs via yearly tenders for the public
sector, encompassing Ministry of Health (MoH), Royal Medical Services (RMS), University hospitals (King Abdullah,
Jordan University Hospital), and King Hussein Cancer Center (KHCC).12,13 The JPD selects the best price (timely
delivery for quantities requested, for example) and not necessarily the lowest price; data on items purchased with
mean price including the 4% tax on drugs are publicly available.12,14 For each product, the award is given to one
supplier or manufacturer; so either a brand or generic drug may be procured. The JPD leverages huge purchasing
power for competitive pricing given the large quantities requested; manufacturers and suppliers still profit due to
the volume and savings exhibited by: no promotions, no product loss attributable to expiry, payment guarantee.15
The private sector (hospitals, pharmacies, etc.) relies on its networks of wholesalers and suppliers importing drugs
from international manufacturers or buying from local manufacturers.16

Access to universal health insurance for all citizens has been a strategic government goal for over the past three
decades.17 The MoH (established in late 1950) with its civil insurance program (established in 1965) provides
coverage for civil servants and their families, the poor, the disabled, persons < 6 years old and those over 60 years
old.18,19 Sources for insurance coverage are conflicting, but perhaps best reflected by the population and housing

5
census of 2015 which determined 68.7% of Jordanians were insured with the following type of coverage - MoH/civil
health insurance at 41.7%, RMS at 38%, private insurance at 12.4%, university hospitals covering 2.5% of the
population, UNWRA (United Nations Relief and Works Agency for Palestine Refugees in the Near East) at 2.5%, and
the remaining by others at 2.5%. Approximately 25% of the 2.9 million non-Jordanians have some form of coverage
reflecting an overall insurance rate among the entire population of approximately 55%.20 Pursuant to another health
policy change in Jordan in end January 2018, Syrian refugees are no longer able to access the non-insured Jordanian
rate for health care but instead pay 80% of the foreigner rate.21

4.2 Pharmaceutical Sector

Pharmaceutical manufacturing is a significant industry in Jordan, comprising approximately 9% of exports.22 The

majority (70-80%) of manufactured products are exported to over 60 countries; Saudi Arabia and Iraq comprise one-
third of the market share.16,22 The Jordanian pharmaceutical market is an open market – local manufacturers, or
suppliers for international manufacturers, can apply to register a drug; the process is the same for both except that
preference is given to the 1 st and 2 nd generics or other added value drugs.11 However in other markets such as United
Arab Emirates, local manufacturers are given preference making it much more challenging for Jordanian
manufacturers to compete. Given Jordan’s positive trade balance in pharmaceuticals, local manufacturers need to
cater to export markets in terms of labeling, product packaging and language – all additive costs.23 The main driver
for local manufacturers and suppliers is profitability; data gathered by Intercontinental Marketing Services (IMS)
Health are used to forecast sales, determine renewal (or not) as well as perform other market analyses - “to be the
first generic on the market”.11,24 Suppliers also have agreements with larger private clients to ensure competitiveness
in a regulated and fixed margin market via bonuses but this practice puts lower priced generics at a disadvantage.16

5. KEY FINDINGS AND ANALYSES

5.1 Availability

Availability has historically been defined in terms of a prescribed medicine being in stock when required; part of this
component would therefore require that essential medicines for NCDs be registered with the JFDA. Using publicly
available data from the JFDA,25 the potential availability of defined NCD drugs in terms of pharmacological class,
dosage, innovator (brand) or generic was characterized. Additionally, a further examination of sub-classes of drug
categories to better understand product availability, particularly those with major market shares as well as quantify
availability of fixed-dose combinations (FDCs), was undertaken. Similarly, for the publicly available JPD data,14
purchased drugs for NCDs for the public sector were described in terms of pharmacological class, dosage and
quantity. Additionally, total monthly regimens for classes and/or individual drugs were quantified for availability of
drugs in the public sector (Appendix A, Box 2).

5.1.1 Quantitative findings and analysis

Of the 12,960 entries in the JFDA dataset, 5758 or 44.4% were registered as drugs; 56 did not have an
INGREDIENT/generic name listed and therefore were excluded. A total of 5702 registered entities were included as
part of the analysis. Nineteen local manufacturers produced 2465 or 42.8% of all registered drug items. There were
a total of 1155 or 20.2% registered drugs for defined NCDs. Of these 1155 drugs, 845 were generics and 624 or 73.8%
were locally manufactured. The import market for NCD drugs included 310 brand and 221 generic drugs totaling 531
of the 1155 NCD drugs or 46% demonstrating the dominance in local manufacturing in this segment.

6
Regarding NCD drugs, almost half (606 products or 52.5%) were indicated for hypertension or CVD while 187 drugs
(16.2%) were indicated for diabetes; remaining drugs were distributed as follows: asthma or COPD, 105 or 9.1%;
epilepsy, 99 or 8.6%; psychiatric illnesses (including treatment for extra-pyramidal symptoms (EPS)), 148 items or
12.8%; and thyroid disease (hypo- or hyper-), 10 or 0.87%. In terms of FDCs, 163 or 14.1% were registered; the
majority (74.8% or 122) were indicated for hypertension or CVD, 25 products for diabetes and 16 for either asthma
or COPD (Appendix B, Table 1).

For publicly procured drugs, (extracted directly from JPD data summary)14 generics comprised 61% of all products
purchased (544 items) compared to 352 brands. Foreign manufacturers comprised the majority of products procured
compared to local manufacturers, 64.6% versus 36%, respectively. In terms of reason for the award, for 58.4% it was
the only offer and for 38.1% due to the lowest offer.

A total of 160 drugs, including varying dosages, were procured by the JPD for NCDs as defined here. The majority,
41.9% or sixty-seven drugs, were for hypertension or CVD, 28 products or 17.5% for treatment of diabetes including
11 insulin products but no FDCs. Twenty-seven products (16.9%) were procured for asthma or COPD; twenty-three
for epilepsy as well as the essential medicines for treatment for thyroid disease. Finally, for psychiatric illnesses, a
total of 12 products were procured; four antipsychotics and for treatment of depression, tricyclic antidepressants
(TCAs) and selective serotonin reuptake inhibitors (SSRIs) (Appendix B, Table 2).

Overall, all World Health Organization (WHO) essential drugs (oral plus insulin)26 for the specified NCDs were
registered by the JFDA and procured by the JPD. However, availability of individual products on the market is likely
dictated by market demand. Manufacturers or suppliers with either low product sales or profitability are under no
obligation to re-register their product or keep it on the market. In the private sector, sales and marketing forces have
huge influences at the prescriber and retail level and may explain why certain products dominated individual classes,
e.g. valsartan comprised 48.2% of all angiotensin II receptor blockers (ARBs), atorvastatin constituted 42.6% of its
class versus the other five statins. Specifically, among statins branded generics predominated with only 11 innovator
drugs registered and with 67 (80.7%) of 83 generics locally manufactured. Multiple manufacturers and suppliers
have registered similar products to compete for market share, thus various packaging sizes by varying suppliers are
available. The dominance of drugs for hypertension and CVD reflects the burden of disease in the population.

5.1.2 Evidence from the literature

Several survey instruments have been used to assess medicine availability and while limitations do exist, these
studies provide valuable insight. A 2004 study conducted in Jordan using the WHO/Health Action International (HAI)
methodology27 to assess availability and affordability of medicines found that public sector drugs were competitively
priced (comparable to international reference prices), but often unavailable (median availability of 28%) forcing
individuals to private markets where affordability may be problematic (generic medicines were priced 10 times
higher in private pharmacies but were available 80% of the time).28 More recently, a secondary analysis of surveys
conducted over 2008 to 2015 using the same methodology to assess availability and affordability of NCD medicines
for four disease categories demonstrated that in all income countries, median availability for generics in the public
sector was low and marginally better in the private sector (Table 1).29 Median availability for brand drugs in the
public sector across all three income groups was 0%. However, the availability of either the lowest generic or brand
for CVD medicines in the private sector was greater than 80% across all income groups and in general, median
product availability in the private sector was higher than in the public sector.

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Table 1. Median percentage availability of medicines for four NCDs diseases (CVD, diabetes, COPD, & central
nervous system (CNS) conditions) by World Bank Income group* and sector
Public Sector median availability (%) Private Sector median availability (%)

Lowest price generic Any product Lowest price generic Any product

LIC (n=10) All medicines 40.2% (n=112) 43.3% (n=89) 59.1% (n=111) 66.7% (n=88)

CVD 45.0% (n=34) 82.9% (n=33)

LMIC (n=12) All medicines 54.6% (n=172) 57.6% (n=172) 65.7% (n=190) 68.6% (n=190)

CVD 74.2% (n=80) 88.6% (n=90)

UMIC (n=8) All medicines 56.7% (n=136) 60.2% (n=136) 76.7% (n=132) 90.0% (n=133)

CVD 60.3% (n=58) 93.3% (n=56)

*LIC – Low-income country; LMIC – lower-middle income country; UMIC – upper-middle income country

An analysis of the Prospective Urban Rural Epidemiological (PURE) study data, covering blood pressure-lowering
medicines, statins, and metformin availability from 626 communities in 20 countries between 2009 and 2016,
demonstrated that 90% of communities had at least one blood pressure-lowering medicine at the local pharmacy
surveyed.30 Among the seven upper-middle income countries (UMICs), availability of at least two blood pressure-
lowering medicine was 87% and among high-income countries (HICs) to include United Arab Emirates, availability
was 98% but among lower-middle income countries (LMICs) and low-income countries (LICs) (excluding India)
availability was 72%. Availability of four blood pressure-lowering medicines was high only among HICs at 94%; among
UMICs, LMICs and LICs (excluding India) it was 71%, 47% and 13%, respectively. Another post-hoc analysis of the
PURE study data for cardiovascular medicine availability (angiotensin-converting enzyme inhibitors (ACEIs), beta(β)-
blockers, statins and aspirin) showed similar findings, with poor availability of all four medicines among communities
in LICs (except India), at 3% in rural communities and 25% in urban settings. Availability increased with country
income level, with LMICs at 37% in rural areas, and 62% in urban areas; UMICs at 73% in rural settings and 80% in
urban settings; and HICs at 90% in rural settings and 95% in urban settings.31

Data from a 2014 survey among 1550 urban Syrian refugee households in Jordan found 86.1% of households seeking
and receiving adult medical care the last time it was needed.32 Additionally, 87.4% of adult care seekers (n=1043)
were prescribed medicines during the most recent health visit, of which 89.8% were able to obtain all needed
medications. In the public sector 396 (or 86.7%) of the 457 individuals obtained all medicines prescribed compared
to 346 (or 93.8%) of the 369 individuals who obtained from the private sector and 77 (or 89.5%) of the 86 individuals
from the NGO sector. (For almost half of those individuals (n=48) not obtaining prescribed medicines, this was due
to unavailability in the public facility. Similarly, as previously mentioned, the 2016 MSF survey showed that among
individuals with a NCD seeking care, the vast majority or 95.2% received it. Slightly over half sought care in the NGO
sector, followed by 27% and 18% in the public and private sectors, respectively. Only twenty-five individuals, or 9.6%,
did not seek care due to availability of NCD services, defined by inadequate service quality, unavailability of staff or
service or long waiting lists.7

While the above studies used validated instruments to assess availability, single measurements are not very robust
and current thinking calls for more innovative approaches over costlier surveys.33 The PURE study used the
Environmental Profile of a Community’s Health (EPOCH) instrument, which collected data from one private
pharmacy per community. Household surveys can be subject to recall bias; participants in these surveys were asked

8
for information specific to the past 6 months or beyond. Regardless, availability of medicines for NCDs and especially
for CVD and hypertension, was relatively high among UMICs (Jordan was a UMIC during the PURE study’s time
period) in both the private sector and in urban settings. Among LICs and LMICs, close to 80% availability of essential
medicines for CVD in the private sector has been reported. Among urban Syrian refugees in Jordan, availability of
medicines for major NCDs was approximately 90% among those seeking care.

5.1.3 Government expenditure, fiscal space & out-of-pocket expenditure

Health financing is instrumental to a government’s ability to provide basic health care. In general, governments
provide the major source of financing for health (Jordan’s government contributed 50.6% in 2013)20 and can
furthermore influence policy to steer priorities. Fiscal space, or the ability of a government to provide additional
budgetary capacity for health, without compromising its financial sustainability34 is a key factor.

Jordan exhibited relatively higher general government expenditure on health (GGHE) as a proportion of overall
government expenditure in 2014, compared to the average 10% among MENA countries of the same income group
(Table 2). However, government expenditure on health as a proportion of total health expenditure (THE) was
comparable to the average expenditure of 63.7% (only select MENA countries are shown in Table 2). A threshold of
below 70 to 80% for government spending on health, increases the risk of households falling into fiscal straits, and
is exhibited by LMICs and UMICs in the MENA region.35 In terms of out-of-pocket spending (OOPS) as a share of total
health expenditure, Jordan is well below the MENA average of 31% but just at the threshold of 20%, reflecting a low
likelihood of catastrophic spending. Except for HICs, most other populations in MENA countries rely on OOPS to
finance healthcare.

Table 2. Indicators of government and out-of-pocket health spending for selected MENA countries – 2014
data35,36,37

World Bank income group GGHE % GGE GGHE % THE GGHE % GDP OOPS % THE
Iraq (UMIC) 6.5 37.2 3.4 39.7
Jo rdan (UMIC) 13.7 64.5 7.4 20.9
Lebanon (UMIC) 10.7 51.7 7.4 36.4
Saudi Arabia (HIC) 8.2 73.4 5.1 14.3
Syria (LMIC) 4.8 - - 53.7
Yemen (LMIC) 3.9 16.2 5.6 76.4
** GGHE – General Government Expenditure on Health; GGE – General Government Expenditure; THE- Total
Expenditure on Health; GDP – Gross Domestic Product; OOPS– Out-Of-Pocket Spending

The JPD procured medicines totaling 113.2 million JD in 2016, an increase from 95.3 million JD in 2012. Some of the
increased demand can be attributable to Syrian refugees, however as a percentage of GDP, spending remained
relatively constant (0.43% in 2012 and 0.42% in 2016).14,38,39

Data on availability of medicines in the public sector for Jordan are limited, except from recent household surveys
among Syrian refugees. Quantities purchased by the JPD (supply) should approximate availability in the public sector,
and when paired with prevalence for targeted diseases (demand), can give an indication of the supply-demand
dynamics. Data on disease specific prevalence is sparse and not current, and comparability among sources is difficult
as age cut-offs or populations vary; best estimates for Jordanians were used applying the 2015 age distributions to
the 2016 population figures (Table 3).3,40,41,42,43

9
Since data on utilization of public sector facilities for medicines was not available, several scenarios were used to
understand availability. For any anti-hypertensive medicine, 77.2% or 527,072 annual treatments would be available
if 65% of the estimated hypertensive population accessed a public facility; that said it is more likely that this
population takes multiple medications, in which case availability would be lower. Except for aspirin, availability of
medicines for CVD was high and for diabetes, overall availability low. However, prevalence for diabetes was
estimated for those aged 20 or older and it is more likely that the burden (at least for use of oral agents) is closer to
the CVD prevalence in which case, availability would be 43.6% or 65,492 annual treatments for sulfonylureas and
67.8% or 101,667 annual treatments for metformin, if the public sector was accessed 65% of the time.

Table 3. Availability of medicines for one-year period in the public sector according to disease prevalence and public
sector use*

HYPERTENSION CVD DIABETES

Prevalence 36.5% [age >35] 8% [age >35] 11.7% [age ≥20]
Total population 1,050,110 230,650 638,603
(2016)
9,798,000
Total monthly Availability based on population accessing public sector
doses purchased (one-year treatment)
85% use 65% use 85% use 65% use 85% use 65% use
ACEIs & ARBs 2,162,270 20.2% 26.4% 91.9% 120.2%
β-Blockers 1,832,156 17.1% 22.4% 77.9% 101.8%
Diuretics 1,244,400 11.6% 15.2%
CCBs (includes 1,086,037 10.1% 13.3%
amlodipine)
Any Antihypertensive 6,324,863 59.0% 77.2%
Aspirin 1,023,333 43.5% 56.9%
Statins 1,794,533 76.3% 99.7%
Sulfonylureas 785,900 12.1% 15.8%
Metformin 1,220,000 18.7% 24.5%
Insulin – Mixed 930,400 14.3% 18.7%
Combinations
* Complete list of availability in terms of monthly regimens by class or individual drug detailed in Appendix B, Table
3

5.1.4 Summary

⬧ In Jordan, all essential medicines for NCDs are registered and procured by the government; particularly
for hypertension and CVD, the greatest burden of disease found in the population
⬧ Generics comprised the vast majority of registered NCD medicines with local manufacturers dominating in
this segment
⬧ Public tendering as well as pricing of medicines is transparent in Jordan
⬧ Several studies documented availability of medicines for NCDs in the public sector was limited among LICs
and LMICs
⬧ More recently and among urban Syrian refugees, only a minority reported unavailability of medicines in
the public sector
⬧ Availability in the private sector is higher, reflected by recent surveys among urban Syrian refugees,
evidence from the PURE study and other literature; and is close to 80% among higher income countries
and in urban settings, but also in lower income countries for CVD medicines
⬧ Compared to MENA countries of the same income group, the Jordanian government spends relatively
more on health than neighboring countries while the population has less out-of-pocket expenditure

10
 ⬧ Fiscal space or the ability of a government to provide additional budgetary capacity for health without
compromising its financial sustainability is a key consideration
⬧ Government purchases of medicines (availability) seems sufficient for CVD and most likely hypertension
as well as diabetes for oral glycemic-lowering medicines if 65% or fewer of the affected population
accessed the public sector

5.2 Affordability

Affordability can be loosely defined as the ability to purchase a needed quantity of medicine without causing undue
financial hardship.1 The price of a medicine is only one aspect of affordability; even very low-priced generic medicines
remain out of reach for many LIC and LMIC households.30

5.2.1 Quantitative findings and analysis

[Link] Private sector pricing

Given prices for all registered drugs are publicly available, the data was further analyzed to understand pricing
variation among classes of drugs (if present or not) especially those with major market shares as well as to assess
affordability.

As a class, statins comprised a sizeable market share of CVD drugs (Appendix B, Table 4) and exhibited a range of
prices across products. Among 20mg statins, atorvastatin, pravastatin and rosuvastatin were priced at a higher level
as compared to simvastatin, which was on average one third of the cost. Furthermore, 30 tablets of atorvastatin has
a relatively wide pricing range among local manufacturers and across exported generic manufacturers – among local
manufacturers, unit pharmacy prices ranged from 0.52 JD to a high of 0.69 JD; but the lowest unit price, 0.43 JD was
from a foreign manufacturer. Thus, for a 30-day prescription, the difference between the lowest and highest price
generic would be 10.2 JD. Prices were lower for bulkier quantities - atorvastatin 20mg supplied by Dar Al Dawa, sold
and packaged as 10 tablets, was priced at 0.73 JD per tablet versus 0.67 JD and 0.60 JD for 30 and 500 tablets,
respectively.

Among ACEIs and ARBs, which comprised 12.3% of the registered products for NCDs, enalapril and lisinopril had the
majority of the share with median prices somewhat similar between the drugs (Appendix B, Table 5). The median
unit price for ARBs was 0.25 JD from a low of 0.11 JD to a high of 0.58 JD. However, within drugs of the same dosage,
little variation existed as exhibited by the narrow price range. Innovator drugs comprised 16.1% of all ARBs (Appendix
B, Table 6).

Apart from statins and FDC inhalers, insulin products were priced at a higher level as compared to other NCD drugs
– particularly the “newer” rapid acting and long acting insulins (Appendix B, Table 7). All are branded medications,
with the vials priced at a lower level; however, with only one product for each type, leaving few options. Among the
eight NPH or isophane products registered, the biosimilar vial was priced at a slightly lower level but this was not
the case for the pen-fills as compared to the brand drug (Appendix B, Table 8). Similarly, for the sixteen
bronchodilator + steroid FDCs, pricing was relatively steep given that brands dominated, with a median patient price
of 26.73 JD [range 4.22, 47.53 JD] (Appendix B, Table 9). Among the seven different selective serotonin reuptake
inhibitors (SSRIs), median pharmacy prices ranged from a low of 0.13 JD for generic paroxetine 20mg to 0.85 JD for
generic duloxetine 60mg. A one month’s prescription would generate a difference between the drugs of 28.31 JD.
Even within the same drug, e.g. escitalopram, wide variations in price among doses and between doses existed
(Appendix B, Table 10).

11
[Link] Public sector pricing

Prices for publicly procured drugs can be compared to an international reference price (IRP)44 as a measure of
efficient purchasing power. The medicine price ratio (MPR) was calculated by taking the median unit price of publicly
procured medicines and dividing by the international median unit buyer price for available medicines and adjusting
for the 2016 currency rate.39,45 Publicly procured drugs should ideally have an MPR ≤ 1.

Among drugs for hypertension or CVD, the median MPR ranged from 0.59 to 1.88 across statins, β-blockers, calcium
channel blockers (CCBs), ACEIs and blood thinning medications (Appendix B, Table 11). Of note statins, had a MPR
of 0.59 and amlodipine a MPR of 0.93. Although the median MPR was above one for the remaining classes, several
classes had drugs that were below the MPR as noted by the 25% inter-quartile range for β-blockers and CCBs (0.78
and 0.71, respectively). It is noteworthy to mention that the absolute price differences for certain drugs are minimal;
for example, bisoprolol 5mg tablets had a median JPD price of 0.0127 USD with the IRP actually higher at 0.0462
USD, but the absolute difference per unit is only 0.0335 USD. For diabetes, MPRs for insulin and metformin were
competitively priced as were some sulfonylureas. However, most inhalers for asthma or COPD treatment as well as
drugs for epilepsy were almost twice the IRP although some exceptions existed.

Previous studies have demonstrated the JPD is purchasing competitively, including a study conducted on behalf of
UNWRA that used it as a benchmark to assess its purchasing power.46 Given that JPD uses tenders and only one is
awarded per product, brand drugs can be procured at most likely a greater cost and likely explains some of the
results. Regardless, pooled purchasing does allow the government to exert increased buying power to acquire
competitive pricing. However, there are some unintended consequences in pooling purchases; in the case of Jordan,
the private sector is essentially subsidizing the public sector.16,23 Manufacturers and suppliers can bid for tenders but
to offset some of the “loss” from selling at lower prices; prices in the private sector are higher or target the maximum
ceiling of 80% of the innovator drug. Others have suggested that pooling purchases disrupt normal competition by
increasing market concentration of the same suppliers, for example.47

[Link] Price determinants – competition, generics, packaging

Increasing competition in the market can drive prices, as mentioned previously: among eight generic atorvastatin
20mg - 30 tablet products, a range of pricing exists both within local manufacturers and across manufacturers
(includes products produced by foreign manufacturers), however smaller market shares like lisinopril 20mg with
four different generics were all priced exactly the same (among 28 tablets packaging).

Jordan is mostly an export market16 although local generic manufacturers dominate the NCD drug market share. This
dominance is likely attributable to the Jordanian market being relatively small and therefore not attracting other
larger generic manufacturers, as yet.23,48 Increasing the share of generics in the market may not always result in more
competitive or lower pricing; in Jordan, generics can take up to 80% of the innovator drug price and with the largely
export market and benchmarking at country of origin, local manufacturers are not necessarily inclined to lower
prices. As well with few foreign larger generic manufacturers present in Jordan, there is no guarantee that prices
would decrease as the market can bear current prices. Lack of price transparency for patients and prescribers - so-
called information asymmetry - is also a factor in maintaining high prices for medicines;47 pricing data for medicines
in Jordan is publicly available, but perhaps not readily.

There are some cost savings associated with larger packaged products; patient cost savings for a month’s supply of
atorvastatin 20mg, would be about 2.22 JD (3 packages of 10 tablets totals 28.62 JD, versus 26.4 JD for the 30-tablet
package). The majority of registered drugs were available predominantly in weekly, bi-weekly or monthly quantities.
For private pharmacies, likely these package sizes are easier for stock management, including reducing losses from
expiry. For patients, monthly prescriptions may be convenient and more economical, as those with chronic

12
conditions can bring their (nearly) empty box and receive next month’s prescription, foregoing any consultation
fees49, and the same product with the same packaging will be dispensed each time.

[Link] Affordability per lowest wage metric

Looking at prices in isolation fails to capture the fact that even low prices can still be cost prohibitive for certain
households. Taking income or household expenditure into consideration is a much more reliable and a better
indicator of affordability. The WHO/Health Action International (HAI) metric50 for affordability was thus used, in
which the lowest priced generic and brand price are divided by the wage of the lowest-paid unskilled worker. A ratio
of greater than one days’ wage for a 30-day supply of medicine defined unaffordability. For JFDA data, monthly costs
for the lowest price generic price were determined by taking the patient price and dividing by the package size and
then multiplying by the monthly regimen quantity (daily or twice daily, etc.). Monthly costs for brands were
determined similarly. For the JPD data, the single product price was used. The lowest skilled daily wage (minimum
wage) was determined by taking the monthly wage (220 JD)51 and dividing by 30 days. Additionally, the JFDA
database was filtered by the lowest daily wage affordability cut-off and then reviewed for monthly regimens to
quantify number of affordable products.

Overall, almost one-third of registered individual drugs for NCDs were considered affordable in the private sector.
Examining across specific classes, most were for hypertension or CVD including β-blockers, diuretics and some ACEIs
and ARBs as well as oral medicines for diabetes including sulfonylureas and metformin (Appendix B, Table 12). Insulin
and inhalers for asthma or COPD were essentially unaffordable for private consumers as the majority were only
available as brands; however, generics were also unaffordable at just over one days’ wage for insulin and closer to
almost two days’ wage for inhalers.

In the public sector, the majority of drugs (123 or 76.9%) were affordable even if multiple drugs were prescribed.
For example, two anti-hypertensive medicines + metformin + statin combined would be affordable at approximately
0.3 days’ wage. Thirty-seven drugs were determined to be unaffordable (Appendix B, Table 13). Newer
anticoagulation treatment such as rivaroxaban (Xarelto) both 15 and 30mg were the least affordable, at almost 8
days’ wage. Essentially 50% (12 of 23) of inhaled products were unaffordable – including single agents as steroids,
long-acting beta-2-(β2) agonists (LABAs) and bronchodilators as well as FDCs - with a median number days’ wage of
2.9 [range 1.4, 4.9]. For treatment of diabetes, newer oral agents including repaglimide and dipeptidyl peptidase-4
(DPP-4) inhibitors were unaffordable at median number days’ wage 1.5 [range 1.3, 2.8]; however only a few insulin
products (pen-fills/cartridges) were unaffordable ranging from 2.0 to 2.5 days’ wage. Some anti-epileptic drugs (e.g.
topiramate, valproic acid) were unaffordable at number days’ wage ranging from 1.1 to 2.7. Regardless, the basic
essential medicines for NCDs are affordable in the public sector with few excluded from cost-effective treatment.

Public - private sector comparison

Fifteen products among various disease categories that were also known to be purchased by the JPD in 2016 were
otherwise randomly selected for the public-private sector comparison (Appendix B, Table 14). Overall, the median
days’ wage for the lowest generic was 0.7 days’ wage and 1.5 days’ wage for brand in the private sector and in the
public sector, the median days’ wage was 0.1 days’ wage (no distinction between generic or brand). Most striking
are the vast absolute differences in sector affordability specifically for atorvastatin 40mg at 3.2 days’ wage for the
generic and 4.6 days’ wage for the innovator. Similarly with levetiracetam 500mg, an absolute difference of 2.5 days’
wage and 3.7 days’ wage for generic and brand, respectively; lesser but significant was the insulin mixed 70/30 vial
with an absolute difference of 1 and 1.3 days’ wage.

13
Insulin and inhalers for asthma and COPD reflect relatively higher costs for consumers in both the public and private
sectors as the majority are only available as innovator brands. Worldwide insulin affordability remains problematic
ranging from 3.5 days’ wages for human insulin to 9.5 days’ wages for analogue insulin in the private sector;52
affordability was better in Jordan, ranging from to 1.6 days’ wages for human insulin to 3.8 days’ wages for analogue
insulin in the private sector. Among FDCs, close to 25% were determined to be affordable in the private sector. For
treatment of diabetes, all thirteen sulfonylurea + metformin combinations were affordable based upon once daily
dosing and for hypertension or CVD treatment, mostly combinations of ACEI/ARB/β-blocker/diuretic + diuretic were
less than a days’ wage (median 0.9 days’ wage). Fewer FDCs were procured for the public sector with similar findings
to those of the private sector.

[Link] Evidence from the literature

These findings are largely consistent with the previously mentioned study of availability and affordability of essential
medicines to treat four NCDs. Based on median number of days’ wage, buying the lowest-price generic in the public
sector required no more than one days’ wage except for some COPD and CNS medications in LMICs.29 In the private
sector, unaffordability of the lowest priced generic was only demonstrated among LMICs at 1.4 days’ wage, but for
brand medicines, the median number of days’ wage was higher at 3.1, 3.8 and 2.4 among LICs, LMICs and UMICs,
respectively.

Similarly the PURE study data analyses showed affordability (total monthly cost of medicines < 20% of households’
monthly capacity to pay) among households of one to two blood-pressure lowering medications in LMICs and in
UMICs.30 The addition of metformin increased household-level unaffordability from 6% to 11%; and this rose to 22%
if the lowest cost statin was added to two blood-pressure lowering medications in LMICs. Similarly in UMICs, the
proportion of households that could not afford the addition of metformin to two blood pressure-lowering
medications increased to 19%; with the addition of a statin, unaffordability among households rose to 26%. In the
private sector in Jordan, the lowest priced β-blocker + diuretic would be affordable at 0.7 days’ wage, adding
metformin increases the cost to 0.9 days’ wage, but adding a statin would increase the total cost to almost 3 days’
wage.

Among 1550 urban Syrian refugee households surveyed in 2014, unaffordability of provider costs was the main
reason 64.5% or 109 of 169 individuals did not seek health care the last time it was needed and the second ranked
reason (39.8%) medicines were not obtained for 93 cases in those who sought care.32 Specifically in Irbid
governorate, among 2575 urban Syrian refugees interviewed, 68.1% needed health care, however 30.2% or 529
individuals did not seek it.7 Unaffordability of provider costs was cited as the main reason in 66.6% or 352 individuals.
Risk factors associated with not seeking care included: age (< 60 years less likely), gender (males less likely) and
household economic status with the lowest two quintiles essentially 1.6 times less likely to seek care compared to
the highest quintile. Having household debt was not a significant risk factor.

For Jordan specifically, annual out-of-pocket expenditure (OOPE) on health, adjusting for inflation, increased from
136 JD in 2008 to 215 JD in 2013.53 Higher OOPE (461 JD) occurred among the richest quintile as compared to the
poorest quintile (66 JD), and Amman, housing 42% of the population, had an OOPE of 327 JD. Medicines accounted
for 62.5% of OOPE, with the poorest quintile spending a higher percentage compared to the richest quintile (69.4%
versus 58.5%). Among refugees and vulnerable Jordanians, data collected from the 2017 CARE urban household
survey showed that the largest expenditure was on rent and utilities. Average monthly OOPE on health ranged from
about 20% in non-Syrian refugees, to 25% in Jordanians and 34% in Syrian refugees of income earned from work and
that the large majority reported being in debt (Table 4).8

14
Table 4. Reported income and expenditure among urban refugees and vulnerable Jordanians in 2017

Urban Syrian refugees Other refugees Jordanians

Main income source(s) Work (%) 36.1 22
Assistance from 39.6 47
(i)NGOs (%)
Average income from work (JD) 176 169 195.2
Average rent support (JD) 178 167
Expenditure (JD) 222 204 318.9
Rent/utilities > 2/3 of work income 164 125
Average monthly health 60 31 48
expenditure (JD)
% Reporting debt 88.9 79.6 80.9
Amount of debt (JD) 694 1329
% Unemployed 77.8 65

The capacity to pay without causing financial difficulty has huge implications for whether a household can afford
medicines or other commodities, even in instances where medicines appear to be inexpensive. In India, for example
where medicines are widely available, unaffordability of 23% was reported even with one blood pressure lowering
medication, as compared to other LICs in which unaffordability was 17%. This finding was explained by not only the
relatively higher price of medicines in India compared to other LICs, but also the lower capacity to pay.30

5.2.2 Prescriber and consumer (patient) behavior

In Jordan, prescribing behavior is heavily influenced by suppliers as well as local manufacturers who employ (deploy)
sales representatives targeting doctors and pharmacists.10,15,16,24 Pharmaceutical promotion is highly unregulated
and most continuing education in the private sector is sponsored and organized by the pharmaceutical industry.20
While NCD guidelines exist for hypertension and diabetes, they date back to 2010 and adherence is questionable. A
rational drug list has been in existence since 2006 and is used for procurement of drugs in the public sector; however,
concerns include conflict of interests and limited accountability of members, with these issues not managed by the
committee deciding on the selection of drugs.54 Additionally, the 2016 NHA report20 identified provider prescribing
behavior as one of the major reasons behind pharmaceutical spending in Jordan. In addition to citing diverse medical
background in terms of level of training for physicians and pharmacists, the lack of effective regulatory
pharmaceutical policies are to blame.

Pharmacists in private pharmacies can influence the market and pricing downstream, with a 26% fixed markup and
presumably profit; they potentially can earn more selling higher priced or brand drugs and may have little incentive
to recommend generics.16,28 Relationships between suppliers and pharmacies also presumably change price
determinants; in some cases manufacturers opt to deal directly with pharmacies to cut out the middleman and keep
costs down.16,24 As demonstrated among certain categories of drugs, there were wide price variations and choices,
as is in the number and types of SSRIs, statins and ARBs. Although discouraged via routine visits by the JFDA,49
pharmacies do give concessions to regular customers; pharmacies often receive bonuses (additional quantities of
products free of charge) from suppliers and/or manufacturers; ultimately private pharmacies, suppliers and local
manufacturers need to turn a profit in order to remain in business.

Health seeking behavior of consumers is also potentially responsible for high pharmaceutical expenditures in
Jordan.20 Specifically the practice of self-medication is one concern, where patients refer themselves to pharmacies
for care and pharmacists in turn prescribe higher priced drugs; thus, behavior and expectations need to be managed.
The availability of innovator drugs is likely linked to prescriber as well as individual behavior, including low

15
acceptance of generics; and preference for brand over generic or for newer items in place of other more affordable
or cost-effective medicines. Psychological factors can result in individuals equating price with quality, creating a
barrier to using generic medicines and potentially more affordable treatment. 47 Current laws in Jordan do not allow
for automatic generic substitution. The same is true in the United Kingdom, yet there, generic prescribing is common,
given both financial incentives and the provision of information for physicians on the impact of cost-savings.47
Rather, arguments can be made for encouraging generic prescribing even where competent staffing disfavors
automatic substitution. Several small studies conducted in Jordan indicate support for generic substitution by
patients and prescribers, but with caveats – prescribers wanted to be informed prior to substitution and patients
preferred to be informed of cheaper alternatives but retain the option to choose.55,56

Among urban Syrian refugees in Irbid governorate, affordability was cited as a barrier to accessing health care, yet
individuals still sought care in private facilities - 42.2% of 1223 individuals received care in a private clinic or hospital,
28.4% in the public sector and 25.3% in the NGO sector.7 In a separate survey among urban Syrian refugees, although
51.5% sought care in public facilities, 38.7% used private facilities, with lower socioeconomic quintiles defined by
expenditure more likely to seek public sector care. Compared to the care seekers in the North, r esidents of southern
Jordan were 7.8 times (CI: 1.83, 33.23) more likely to use public sector facilities versus in central Jordan (Amman)
who were twice as likely to use the private sector.32 Among Syrian refugees and vulnerable Jordanians respondents,
perceived better quality of treatment, personal preference as well as the only health facility in the area were cited
as reasons they sought private sector care.7,8

5.2.3 Summary

⬧ In the private sector, prices are relatively fixed but pricing variability among and between classes is
present
⬧ The pharma sector is intricately linked to available prices in Jordan given competition for market share,
profitability (generics can take up to 80% of the innovator drug price) and managing its predominantly
export market
⬧ The Jordanian pharma market is relatively small and does not attract larger foreign manufacturers,
possibly limiting competition
⬧ Competitive pricing (comparable to international reference prices (IRPs)) exists for the majority of NCD
drugs procured by the government
⬧ The majority of NCD medicines were affordable (less than one days’ wage) in the public sector, including if
multiple drugs were prescribed for hypertension, CVD and/or diabetes
⬧ Overall almost one-third of individual drugs for NCDs are affordable in the private sector - mainly among
medicines for hypertension or CVD and oral medicines for diabetes and largely consistent with findings in
the literature
⬧ Insulin and FDC inhalers for asthma or COPD were largely unaffordable across both sectors reflected by
the predominance in branded drugs
⬧ Capacity to pay without causing financial hardship has huge implications on whether a household can
afford medicines or other commodities even in instances where medicines appear to be relatively
inexpensive
⬧ Affordability of provider costs is the main barrier for seeking and receiving health care in a minority of the
population and is most likely linked to capacity to pay (the majority of the population reported debt)
⬧ Prescriber and consumer (patient) behavior plays an integral role in affordability with prescribers
recommending less cost-effective options given little incentive to do otherwise and consumers preferring
to self-medicate and/or seek private care or brand drugs

16
5.3 ACCESSIBILITY

Accessibility is essentially the ability to access medicines when needed.1 Jordan has 110 hospitals and a range of
facilities in the public and private sector, where staffing levels are close to regional standards (Table 5).3,19,37 Prior to
2016, Jordan exceeded the global average for UMICs for physician density, with 16.1 per 10,000 population.57 The
decline to 14.1 per 10,000 population since 2016 is most likely two-fold; physician attrition given its labor market is
inclusive of Saudi Arabia and Gulf states, and the Syrian refugee influx.17,19

Table 5. Health service delivery and workforce for selected MENA countries by World Bank income group – 2016
data

Personnel per 10,000 population

World Bank income group Hospital beds per 10,000 Physicians Nurses and
population midwifery
Iraq (UMIC) 13 8.4 19.4
Jordan (UMIC) 14 14.1 18.9
Lebanon (UMIC) 27.3 31 34.2
Saudi Arabia (HIC) 22.3 23.9 57.0
Syria (LMIC) 14.6 12.2 14.6
Yemen (LMIC) 7.1* 3** 7.3**
* 2013 data; ** 2014 data

Geographically, Jordan is a small country with a functioning infrastructure; thus transportation and physical access
to healthcare are unlikely to be substantial impediments.16 In fact, Jordan’s MoH states that every citizen is within a
30-minute driving distance to one of its hospitals.19 Physical accessibility is an issue for a minority of refugee
populations, in which it is reported some seek private sector care due to no public health facility in the area (and
thus compounding the affordability issue), but also due to affordability of provider fees and medicine or
transportation costs.7,8,32

An analysis of survey data collected from 2008 to 2010 assessed factors associated with accessibility of chronic
disease medicines among five LICs and LMIC.58 It documented that about half of individuals surveyed in Jordan during
2010 (n=583) had access to medications to treat chronic disease compared to the Philippines (38%), Ghana (35%)
and Kenya (33%). Predictors of having access to medicines included having some insurance coverage or obtaining
medicines free-of-charge and for three of the surveyed countries (Ghana, Kenya and Jordan) living in the capital city.
Yet, living within 15 minutes of a public healthcare facility increased the likelihood in Uganda and the Philippines,
but not for individuals in Jordan who were 20% less likely to access medicines for chronic disease.

It is noteworthy to mention that accessibility does not mean that the most appropriate medicines are at hand. In
fact, accessibility has “largely trumped” appropriate use according to one report largely because there is no
ownership and stakeholders often have vying objectives or incentives.59

5.3.1 Summary

⬧ Jordan nears regional standards in health service delivery and workforce metrics, yet considerably lower
than Lebanon
⬧ With regard to geography and infrastructure – limited if any barriers exist to accessing health care
⬧ Accessibility is a barrier for a minority of refugee populations seeking care due to lack of public facility or
costs associated with provider fees, medicines or transportation

17
 ⬧ Survey data from 2008 to 2010 among five lower income countries documented low accessibility to
medicines for treating chronic disease; Jordan was the highest at about 50% of individuals accessing
medicines
⬧ Accessibility does not imply that medicines are appropriate or being used correctly

6. PREVENTION

Four of the nine global voluntary targets comprising WHO’s global action plan for the prevention and control of non-
communicable diseases are modifiable behavioral risk factors.60 For Jordan in particular, the importance of
prioritizing prevention should be emphasized on two levels - in the health sector, to improve resource utilization and
costs incurred; and for individuals, to potentially reduce morbidity and mortality and decrease out-of-pocket
expenditure on health.

In terms of risk factors, Jordan has very high levels of modifiable behavioural risk factors as compared to global
averages as well as levels in other MENA countries.35 Jordanian men smoke at a rate of almost twice the global
average, with a prevalence of 63.6%. Prevalence of obesity among Jordanians and Syrians is also above the global
average, especially for women, where obesity prevalence is close to 40% for Jordanians and 30% for Syrians, as
compared to the global average of 15.2%. Additionally, 2016 global burden of disease (GBD) data for Jordan indicates
the risk factors driving the most death and disability included high-body mass index (ranked number one), dietary
risks (ranked four) and tobacco (ranked six); for Syrians, the number one ranked factor was dietary risks, followed
by high-body mass index ranked third and tobacco ranked fifth.5,6
In terms of healthcare resource utilization, among urban Syrian refugees surveyed in the 2016 MSF study, joint pain
was the second main reason that males (124 among 673 adult men), and fourth main reason that females (145
among 1080 adult women), sought care.7 Additionally, the GBD data profile on Syria and Jordan, ranked low back
and neck pain as the number one health problem causing disability, with other musculoskeletal problems ranked
tenth for Syrians and eighth for Jordanians.5,6 There most likely exists a link between these health problems and the
prevalence of obesity.

The MoH has a separate budget for smoking cessation and health awareness campaigns and it has been
recommended that it broaden use of primary care to harness behavior change communication as well as take greater
ownership for prevention.19 Fiscally, spending more money on preventing chronic disease is the best way to reduce
curative care costs. Evidence for increasing or establishing excise or so-called “sin” taxes on unhealthy consumer
products such as tobacco and high-sugar drinks have demonstrated value, additionally increasing fiscal space
towards attaining universal health coverage.19,35

Finally, coming back to affordability, the latest population and housing census data from 2015, indicates that
annually, Jordanians across all governorates are spending more on tobacco than medical expenses - almost double
or more (except in Amman) (Table 6).40 Additionally, with increasing household size, the average annual expenditure
on tobacco increased (from 215.1 JD in households of 1 to 2 up to 871.8 JD in households of > 15) with no correlation
in medical expenses (increase or decrease).

18
Table 6. Average annual household income and expenditure by region (2013 data)

Income (JD) Expenditures (JD)

Total From employment Total Tobacco & cigarettes Medical care
% of total Total % of work Total % of work
income income
Kingdom 9258.0 4326.2 46.7 10251.6 480.7 11.1 214.6 4.9
Urban 9447.2 4367.5 46.2
Rural 8331.3 4123.9 49.5
Amman 10716.1 4613.9 43.1 12078.6 466.8 10.1 327.2 7.1
Irbid 9009.0 4064.4 45.1 9616.4 492.1 12.1 137.4 3.4
Mafraq 7749.8 3982.5 51.4 8516.0 427 10.7 118.8 2.9

7. LIMITATIONS

As previously alluded to, while household surveys provide a wealth of information, they can be limited in terms of
methodology. The health access and utilization surveys may be subject to recall bias influencing responses. The
validated instruments used in several studies to assess availability and affordability visited only one pharmacy for
product availability and may not be representative of actual availability. We did not use the “gold-standard”
approach to assess availability and affordability, but rather a more pragmatic one by using existing in-country
health system data. We included most major NCDs but not cancer. Some of the literature referenced for
comparisons were dated. Additionally, calculations for affordability using data from the JFDA and JPD relied on
standard dosing regimens that may not necessarily reflect reality. For example, individuals could be prescribed
treatment more frequently or in higher dosages. WHO’s global action plan for prevention and treatment of NCDs,
sets a voluntary global target of achieving availability of affordable essential medicines to treat major NCDs in both
public and private facilities at 80%60 – unfortunately our investigation did not simultaneously examine availability
and affordability, yet it still provides a current snapshot of progress towards this goal.

8. CONCLUSIONS

Overall accessibility to medicines for major NCDs in Jordan is relatively high with a minority of the population not
accessing treatment mainly due to affordability (predominantly provider costs, but also medicines and
transportation costs). This is most likely linked to capacity to pay given expenditures exceed income among urban
refugees and Jordanians and while, debt was not a factor in not seeking care in one study, the majority of the
population report debt. It is imperative to understand that prices of medicines cannot be examined in a vacuum.

Jordan has sufficient healthcare resources and government expenditure on health exceeds that of many MENA
countries of the same income group. Overall, all WHO essential drugs (oral plus insulin) for the specified NCDs are
registered with the JFDA and the majority are being procured at competitive prices (comparable to the
international reference price (IRP)) by the government. Public tendering as well as pricing of medicines is
transparent in Jordan. In the private sector, prices are essentially fixed by law, but heavily influenced by the
pharma sector whose priorities lie with profitability and in general, the predominant export market. There is
essentially limited to no space for external influence.

According to the literature, in general among lower income countries investigated, public sector availability of
medicines for NCDs was limited. However, only a minority of urban Syrian refugees reported unavailability of
medicines in the public sector. According to the same literature, availability in the private sector is higher and close

19
to 80% among higher income countries and in urban settings, but also in lower income countries for CVD
medicines. These findings should hold true for Jordan.

The majority of NCD medicines were determined to be affordable (less than one days’ wage) in the public sector
including if multiple drugs were prescribed for hypertension, CVD and/or diabetes. Affordability in the private
sector is predominantly among medicines for hypertension or CVD and oral medicines for diabetes; notable
exceptions include insulin, FDCs for inhalers as well as statins. Higher costs can be attributable in part to personal
prescriber practices and consumer preferences.

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.

9. 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.

20
10. REFERENCES

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24
11. APPENDICES

Appendix A

Box 1

JFDA pricing lawsa

– Price of originator (innovator) drug is the lower of 4 benchmarks:

a. Export price (manufacturer listed invoice price)
b. Public price in country of origin – VAT & wholesaler/pharmacy profits + shipping, bank charges,
insurance, clearing & inland transportation costs
c. Median public price from the following 17 countries: Britain, France, Spain, Italy, Belgium, Greece,
The Netherlands, Australia, Cyprus, Hungary, Ireland, New Zealand, Portugal, Czech, Croatia and
Austria
d. Public price in Saudi Arabia
– Price of generic (branded generic) drug; essentially as above AND requested price cannot exceed 80% of
the price of originator drug

a. Jordan Food and Drug Administration (JFDA). Drug pricing guidelines for the year 2016. The Official Gazette. Issued in session
No. 39; 29 Dec 2015

25
Box 2

Jordan Food & Drug Administration (JFDA) data

The 2017 dataset listed all drugs and other items such as herbals, cosmetics, drugs, vaccines, infant formula, etc.
per product with details on name brand, dosage, supplier and manufacturer information as well as price; price
reflected: (1) pharmacy obtained price; (2) patient price – a fixed 26% markup; and (3) patient price including tax–
fixed 4% tax( with the exception of insulin, all drugs are taxed).

Data was first filtered on “List Class Specification” for drugs to obtain the working dataset. Local manufacturers
were identified and coded accordingly. Drugs were classified as a NCD drug largely based on the 2018 MSF NCD
programmatic and clinical guidelinesb for asthma, chronic obstructive pulmonary disease (COPD, diabetes,
hypothyroidism or hyperthyroidism, epilepsy, cardiovascular disease (CVD), hypertension and psychiatric illnesses
(depression, psychosis). Drugs for treatment of cancer, pain (e.g. non-steroidal anti-inflammatory drugs (NSAIDs)
or gastrointestinal illnesses including proton pump inhibitors (e.g. omeprazole) H2 blockers (e.g. ranitidine),
atypical antipsychotics (except risperidone) or benzodiazepines were not included); insulin was the sole injectable
drug included in the analysis. Newer drugs for example, Dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins) for
treatment of diabetes were included as were fixed-dose combinations (FDCs); other drugs used for chronic
conditions specified were also included, e.g. amiodarone, aminophylline.

Each product was coded either as brand or generic drug. FDCs were identified and coded accordingly. Each product
was also coded by disease category (CVD and hypertension were grouped as one as were asthma and COPD) and
within categories by drug type, e.g. beta (β)-blocker, statin, insulin, etc. Detailed analyses were executed on
categories of drugs to demonstrate and understand larger market share categories, supplier and manufacturer
competition and pricing. Median unit price was calculated by dividing the pharmacy price by package size over the
same drug and strength; taking the low and high values to determine the range. Innovator drugs were excluded
from the median unit price calculations.

Joint Procurement Department (JPD) data

The 2016 JPD dataset acquired had single entries for individual drugs categorized by disease category with total
quantities purchased, mean unit price of purchase and total value of purchase. For example, atenolol 50mg tablets
were listed under “Cardiovascular System Drugs” with a total quantity of 12,555,000 tablets purchased for an
average price of 0.007 Jordanian Dinar (JD) per tablet. Only JFDA registered drugs were purchased and only either
innovator brand or generic per item. Affordability was determined using the number of days’ wage metric as per
the JFDA analyses.

b. Médecins sans Frontières (MSF). Non-communicable diseases – Programmatic and clinical guidelines; 2018 (version3)

26
Appendix B.

Table 1. Essential medicines for major NCDs registered by disease category and pharmacologic class (only major
class shares listed for individual drugs)

Disease category with pharmacologic class n=1155 (%)

Hypertension or CVD n=606 (52.5)
⬧ Diuretics - furosemide; spironolactone; hydrochlorothiazide (HCTZ) 31 (5.2)
⬧ Beta (β)-blockers - bisoprolol (21); atenolol (19); carvedilol (9); 5 others (10) 59 (9.7)
⬧ Angiotensin-converting enzyme inhibitors (ACEIs) - enalapril (24); lisinopril (24); 7 others (38) 86 (14.2)
⬧ Angiotensin II receptor blockers (ARBs) - valsartan (27); 6 others (29) 56 (9.2)
⬧ Statins - atorvastatin (40); rosuvastatin (27); 4 others (27) 94 (15.5)
⬧ Calcium channel blockers (CCBs) – amlodipine (28); nifedipine; diltiazem; verapamil; 2 others 51 (8.4)
⬧ Other – Fibrates/lipid lowering (10); vasodilators/anti-anginal agents (23); anti-coagulants (11); 107 (17.7)
anti-platelet aggregates (24); amiodarone, digoxin, other anti-hypertensives including methyldopa
(19)
⬧ FDCs - 10 varying combinations; diuretic + ACEI, ARB, β-blocker or other diuretic (65); CCB +ACEI, 122 (20.1)
ARB or statin (37); triple combination – ARB + CCB + diuretic (15)
Diabetes n=187 (16.2)
⬧ Sulfonylureas - glimepiride (44); glibenclamide (13); 3 others (10) 67 (35.8)
⬧ Metformin 500 to 1000mg 40 (21.4)
⬧ Other - pioglitazone; empagliflozin (competitive inhibitor of sodium-glucose co-transporter 2 18 (9.6)
(SGLT2)); repaglinide (meglitinide); Dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins) (5) -
linagliptin, saxagliptin, sitagliptin, vildagliptin
⬧ Insulin - (vials, cartridges or penfills) Fast-acting - lispro, regular, aspart; long-acting - isophane, 37 (19.8)
detemir, glargine; mixed combinations
⬧ FDCs - metformin + sulfonylureas (13), + DPP-4 inhibitors (10) 25 (13.4)
Asthma or COPD n=105 (9.1)
⬧ Steroids (oral & inhaled) - prednisolone (oral); beclomethasone, fluticasone, budesonide, 19 (18.1)
mometasone
⬧ beta-2-(β2) agonists short-acting (SABA) - salbutamol oral & inhaled (20) & long-acting (LABA) – 30 (28.6)
(10) salmeterol, formoterol, indacaterol
⬧ Other – bronchodilators (22) - theophylline, ipratropium, tiotropium & terbutaline; montelukast 40 (38.1)
(18)
⬧ FDCs – SABA + bronchodilator; LABA + bronchodilator or steroid 16 (15.2)
Epilepsy n=99; (8.6)
⬧ Carbamazepine (17); valproic acid or sodium valproate (17); levetiracetam (25); phenytoin or 64 (64.6)
phenobarbital (5)
⬧ Other - lamotrigine (23); topiramate (6); oxcarbazepine (4); lacosamide (2) 35 (35.4)
Psychiatric illnesses (includes treatment for extra-pyramidal symptoms (EPS)) n=148; (12.8)
⬧ Tricyclic antidepressants (TCAs) – amitriptyline, imipramine 10 (6.8)
⬧ Selective serotonin reuptake inhibitors (SSRIs) - citalopram (14); escitalopram (13); fluoxetine (19); 65 (43.9)
sertraline (10); 3 others (9)
⬧ Antipsychotics - risperidone (55), 2 others (6) 73 (49.3)
⬧ Trihexyphenidyl (treatment of EPS) (12)
Thyroid disease (hypo- or hyper) 10 (0.87)
⬧ Carbimazole (2) 10 (100)
⬧ Levothyroxine 25, 50, 100, or 150 micrograms (mcg) (8)

27
Table 2. Essential medicines for major NCDs purchased by the JPD for the public sector by disease category and
pharmacologic class
Disease category with pharmacologic class n=160 (%)
Hypertension or CVD n=67 (41.9)
⬧ Diuretics - furosemide; spironolactone; hydrochlorothiazide (HCTZ); indapamide 5
⬧ Beta (β)-blockers – bisoprolol, atenolol, carvedilol, metoprolol, nebivolol, propranolol, betaxolol 11
⬧ Angiotensin-converting enzyme inhibitors (ACEIs) – enalapril, captopril 9
⬧ Angiotensin II receptor blockers (ARBs) - valsartan, candesartan
⬧ Statins – atorvastatin; simvastatin; rosuvastatin; fluvastatin 6
⬧ Calcium channel blockers – amlodipine, nifedipine, diltiazem, verapamil 8
⬧ Other - Fenofibrate, gemfibrozil; vasodilators/anti-anginal agent (ISDN, trimetazidine); anti- 23
coagulants (warfarin, rivaroxaban, dabigatran); anti-platelet aggregates (acetylsalicylic acid,
clopidogrel, dipyridamole, ticagrelor); anti-arrhythmics (amiodarone, flecainide); digoxin; other anti-
hypertensives (methyldopa, moxonidine)
⬧ FDCs - diuretic + ARBs, diuretic + diuretic 5
Diabetes n=28 (17.5)
⬧ Sulfonylureas – glimepiride (5), glibenclamide, gliclazide 9
⬧ Metformin 500 to 1000mg 3
⬧ Other - repaglinide (meglitinide); DPP-4 inhibitors - saxagliptin, sitagliptin, vildagliptin 5
⬧ Insulin - (vials, cartridges or penfills) fast-acting (4)– lispro, regular & aspart; long-acting (3) - 11
isophane, detemir, glargine; mixed combinations (4) (70/30 isophane/human & 70/30 aspart, 50/50
lispro)
Asthma or COPD n=27 (16.9)
⬧ Steroids (oral & inhaled) - prednisolone (oral); beclomethasone, fluticasone, budesonide, 9
mometasone
⬧ beta-2-(β2) agonists short-acting (SABA) - salbutamol oral & inhaled (4) & long-acting (LABA) – 8
formoterol (2), indacaterol (2)
⬧ Other – bronchodilators- theophylline, ipratropium, tiotropium, glycopyronium 4
⬧ FDCs – SABA (1), LABA (4) with steroid; bronchodilator + LABA 6
Epilepsy n=23 (14.4)
⬧ Carbamazepine (4), valproic acid or sodium valproate (7), levetiracetam (2), phenytoin or 17
phenobarbital (4)
⬧ Others - lamotrigine (3), topiramate (3) 6
Psychiatric illnesses (includes treatment for extra-pyramidal symptoms (EPS)) n=12 (7.5)
⬧ Tricyclic antidepressants (TCAs) – amitriptyline, imipramine 3
⬧ Selective serotonin reuptake inhibitors (SSRIs) – citalopram, fluoxetine, fluvoxamine, paroxetine 5
⬧ Antipsychotics - risperidone, haloperidol 4
Thyroid disease (hypo- or hyper) n=3 (1.9)
⬧carbimazole, levothyroxine (50, 100 micrograms only) 3

28
Table 3. Total monthly doses purchased for the public sector by class or drug with standard dosing regimens
Total monthly
Drug class or individual drug Dosing regimen doses

Beta (β)-blockers - all Once daily; except carvedilol twice daily; propranolol three times daily 1,832,156
- Bisoprolol only 5 & 10mg once daily 904,900
ACEIs only (no FDCs) Once daily; except captopril - twice daily 1,721,937
ARBs only (no FDCs) Once daily 440,333
Diuretics Once daily; including FDC - diuretic + diuretic 1,244,400
- Furosemide only 40mg once daily 850,000
Once daily; except - diltiazem & verapamil (non-SR) - three times
Calcium channel blockers daily; nifedipine retard - twice daily 1,086,037
- Amlodipine only 5mg once daily 888,000
Statins - all Once daily 1,794,533
- Atorvastatin only 20 & 40 mg once daily 886,667
- Simvastatin only 20mg once daily 894,667

Acetylsalicylic Acid (aspirin) 100 mg once daily 1,023,333

Sulfonylureas Once daily 785,900
- Glimepiride 1, 2, 3, 4 or 6mg once daily 745,133
Metformin Twice daily 1,220,000
Regular, aspart, lispro - twice to three times daily (up to 9 -10 mL
Insulin - fast acting depending on vials, cartridges or penfills) 42,517
Insulin - long acting Detemir, glargine, isophane - once to twice daily (up to 10 mL) 120,900
70/30 - isophane + regular or aspart; lispro 50/50 - twice daily (up to
Insulin - mixed combinations 9 -10 mL depending on vials, cartridges or penfills) 930,400

- isophane + regular 70/30 only Twice daily (up to 9 -10 mL depending on vials, cartridges or penfills) 914,500
Prednisolone 10mg once daily 116,667

Steroids - inhaled 1 puff or 1-2 puffs twice daily; except budesonide solution - once daily 59,640
Salbutamol 0.5 % - 0.5-1ml four times daily or salbutamol 100 mcg 2-
SABA - inhaled 4 puffs twice daily 318,767
FDCs - asthma/COPD SABA or LABA + bronchodilator; LABA + steroid 35,527
Budesonide + Formoterol - 2 puffs twice daily; salmeterol +
- LABA + steroid only fluticasone 1 puff twice daily 30,500
Carbamazepine Children 400-600mg/day; Adults 800-1200mg/day divided twice daily 160,723
Sodium valproate or valproic
acid 20-30mg/kg twice daily 83,580
SSRIs Once daily 46,067
Levothyroxine 50 or 100mcg once daily 401,833

29
Table 4. Registered 20 mg statins in terms of packaging size, supplier, manufacturer and unit price
*Highlighted cells indicate local manufacturers **Innovator brands are denoted in bold
Name No. Unit
Brand doses Dosage Supplier Manufacturer price (JD)
ATORVASTATIN 20 MG
Lipodar 10 Tablet Dar Al Dawa Development & Investment Co. Ltd/DAD Dar Al Dawa Development & Investment Co. Ltd/DAD 0.7280
Aditor 20 Tablet The Arab Pharmaceutical Manufuring Company The Arab Pharmaceutical Manufactruing Co. 0.6780
Aditor 30 Tablet The Arab Pharmaceutical Manufuring Company The Arab Pharmaceutical Manufactruing Co. 0.6780
Lipodar 30 Tablet Dar Al Dawa Development & Investment Co. Ltd/DAD Dar Al Dawa Development & Investment Co. Ltd/DAD 0.6713
Lipover 30 Tablet Jordan River Pharmaceutical Industries Jordan River Pharmaceutical Industries 0.5160
Torvacol 30 Tablet Jordan Pharmaceutical Manufacturer (JPM) Jordan Pharmacuticals Manufacture (JPM) 0.5233
Lipomax 30 Tablet Ibn Rushd Drug Store SAJA-Saudi Arabian Japanese Pharma. Co. 0.6570
Tulip 30 Tablet Nabulsi Drug Store LEK Pharm. and Chemical Work 0.6147
Vastor 30 Film-coated Hikma Pharmaceuticals Hikma Pharmaceuticals 0.6863
Tovast 30 Tablet Regional Drug Store Spimaco (Sudi Pharmacutical Industries & Medical 0.4260
Appliances Corp)
Lipitor 30 Tablet Sabbagh Drug Store Pfizer Pharmaceuticals Vega Baja /USA 0.8577
Vastor 90 Film-coated Hikma Pharmaceuticals Hikma Pharmaceuticals 0.6450
Lipodar 500 Tablet Dar Al Dawa Development & Investment Co. Ltd/DAD Dar Al Dawa Development & Investment Co. Ltd/DAD 0.6042
Lipover 1000 Tablet Jordan River Pharmaceutical Industries Jordan River Pharmaceutical Industries 0.4385
Atorvast 1050 Tablet Jordan Sweden Medical & Sterilization Co. Jordan Sweden Medical & Sterilization Co. 0.4097
PRAVASTATIN 20 MG
Lowchol 30 Tablet United Pharmaceutical Manufacturing Co. Ltd. United Pharmaceutical Manufacturing Co. Ltd. 0.3673
Lipostat 30 Tablet Suleiman Tannous & Sons Co. Ltd Bristol Myers Squibb Company Evansville Indiana 0.4593
ROSUVASTATIN 20 MG
Eveness 28 Film-coated Pharma International Company Pharma International Company 0.7236
Scolta 30 Film-coated United Pharmaceutical Manufacturing Co. Ltd. United Pharmaceutical Manufacturing Co. Ltd. 0.6657
Supersta 30 Tablet Hikma Pharmaceuticals Hikma Pharmaceuticals 0.7233
tRosatin 30 Tablet Al-Taqqadom Pharmaceutical Industries Al-Taqqadom Pharmaceutical Industries 0.7233
Rosakit 30 Film-coated Jordan Pharmaceutical Manufacturer (JPM) Jordan Pharmacuticals Manufacture (JPM) 0.6207
Joswe 30 Tablet Jordan Sweden Medical & Sterilization Co. Jordan Sweden Medical & Sterilization Co. 0.5343
Corteza
Zerova 30 Film-coated Savvy Pharma Savvy Pharma 0.7233
Excor 30 Tablet Hayat Pharmaceutical Industries [Link] Hayat Pharmaceutical Industries [Link] 0.7233
Rozitta 30 Film-coated Dar Al Dawa Development & Investment Co. Ltd/DAD Dar Al Dawa Development & Investment Co. Ltd/DAD 0.5000
Rozitta 500 Film-coated Dar Al Dawa Development & Investment Co. Ltd/DAD Dar Al Dawa Development & Investment Co. Ltd/DAD 0.6295
SIMVASTATIN 20 MG
Sivacor 10 Tablet The Arab Pharmaceutical Manufuring Company The Arab Pharmaceutical Manufacturing Co. 0.1900
Sivacor 30 Tablet The Arab Pharmaceutical Manufuring Company The Arab Pharmaceutical Manufacturing Co. 0.1793
Syvast 28 Film-coated Professional Drug Store Julphar 0.1793
Vasta 30 Film-coated Sukhtian Group Tabuk pharmaceutical Manufacturing Co. 0.1793
Lipomid 30 Film-coated Middle East Pharmaceutical And Chemical Industries Middle Est Pharmaceutical & Chemical Industries 0.1793
ZOCOR 30 Tablet Adatco Drug Store Merck Sharp & Dohme Ltd 0.2243

30
Table 5. Median unit prices among two major ACEIs by drug concentrate
*Innovator brands are denoted in bold **Prices without a range reflect only one price or product registered

Ingredient/Generic Name Name Brand Dosage Drug Concentrate Median unit price [range] (JD)
Enalapril Maleate Tablet 5 mg 0.0865 [0.0741, 0.12]
Enalapril Maleate Tablet 10 mg 0.1323 [0.1058, 0.1827]
Enalapril Maleate Tablet 20 mg 0.2275 [0.1749, 0.312]
Lisinopril Tablet 5 mg 0.1099 [0.0935, 0.11]
Lisinopril Zestril Tablet Tablet 5 mg 0.1281
Lisinopril Tablet 10 mg 0.1846 [0.1653, 0.1945]
Lisinopril Tablet 20 mg 0.1943 [0.1653, 0.2043]
Film-coated
Lisinopril Zestril Tablet tablet 20 mg 0.1949

Table 6. Registered ARBs by drug concentrate and median unit price

*Innovator brands are denoted in bold **Prices without a range reflect only one price or product registered
Ingredient/Generic Name Name Brand Dosage Drug Concentrate Median unit price [range] (JD)
Candesartan Cilexetil ATACAND Tablet 4 mg 0.2454
Candesartan Cilexetil ATACAND Tablet 8 mg 0.2454
Candesartan Cilexetil Tablet 8 mg 0.1067
Candesartan Cilexetil Tablet 16 mg 0.4482 [0.448, 0.4707]
Eprosartan Tablet 600 mg 0.5607
Irbesartan Tablet 150 mg 0.2028 [0.2027,0.2539]
Irbesartan Tablet 300 mg 0.2027 [0.1763, 0.2033]
Losartan Potassium Tablet 50 mg 0.1831
Losartan Potassium COZAAR Tablet 100 mg 0.2370
Olmesartan medoxomil Film-coated tablet 10 mg 0.4046
Olmesartan medoxomil Film-coated tablet 20 mg 0.5553
Olmesartan medoxomil Film-coated tablet 40 mg 0.5775
Telmisartan MICARDIS Tablet 40 mg 0.4207
Telmisartan MICARDIS Tablet 80 mg 0.5432
Valsartan DIOVAN Film-coated tablet 40 mg 0.1496
Valsartan Film-coated tablet 40 mg 0.1203 [0.1203, 0.1247]
Valsartan DIOVAN Tablet 80 mg 0.2068
Valsartan Tablet 80 mg 0.1673 [0.1423, 0.1723]
Valsartan DIOVAN Tablet 160 mg 0.2729
Valsartan Film-coated tablet 160 mg 0.2263 [0.1968, 0.2263]
Valsartan Tablet 320 mg 0.3057
Valsartan DIOVAN Film-coated tablet 320 mg 0.3768

31
Table 7. Sample of registered insulin products with patient pricing
Patient
Name Brand Package size Dosage Ingredient/Generic Name Manufacturer price (JD)

NovoRapid Flexpen 5 X 3ml Pre-Filled Pens Solution for injection Insulin Aspart 100 iu/ml Novo Nordisk A/S (Bagsvaerd) 44.03
NovoRapid Penfills 5 X 3ml Cart Solution for injection Insulin Aspart 100 iu/ml Novo Nordisk A/S (Bagsvaerd) 28.21
NovoNordisk Pharmaceutical
NovoRapid Vial 1 X 10ml Solution for injection Insulin Aspart 100 iu/ml Industries Inc 17.88
Novomix 50 flexpen 5 Pen X 3ml Solution for injection Insulin Aspart 100 iu/ml Novo Nordisk A/S (Bagsvaerd) 40.6
Levemir Flexpen Pre
Filled Pen 5 Cart X 3ml Solution for injection Insulin Detemir 100 iu/ml Novo Nordisk Production SAS 56.88
Levemir Penfill 5 X 3ml Penfills Insulin Detemir 100 IU/ml Novo Nordisk A/S (Bagsvaerd) 68.05
Lantus Vial 10 ml Vial Insulin Glargine 100 iu/ml Aventis Pharma 43.5
Humalog Mix 50 5 x 3ml Cartridge Suspension Insulin Lispro 100 iu/ml Lilly France 39.2
Insulins & Analogues, Fast-
Acting 100 IU/ml, Insulin
HUMALOG Vial 1 x 10ml Vial Lispro Eli-Lilly & Company 21.72

Table 8. Available isophane or NPH insulin products with patient pricing

*Innovator brands are denoted in bold
Patient
Name Brand Package size Dosage Ingredient/Generic Name Manufacturer price (JD)
Insuman basal vial 5ml Vial Solution for injection Recombinant Human Insulin 100 IU/ml Aventis Pharma 5
Recombinant Human Insulin Isophane
Gensulin N 10ml Vial Vial 100 iu/ml Bioten S.A 8.6
Insulatard 1 Vial X 10ml Suspension Human Insulin (rDNA Origin) 100 iu/ml Novo Nordisk A/S (Bagsvaerd) 10.79
Human Insulin Isophane (rDNA Origin)
HUMULIN N NPH Vial 1 X 10ml Vial 100 iu/ml Eli-Lilly & Company 11.43
Insuman Basal (100iu/ml) 1 Vial (10ml) Suspension for injection Insulin Human 100 iu Sanofi-Aventis Deutschland GmbH 9.5
Humulin N 5 X 3ml Cart Suspension Insulin Human 100 iu/ml Lilly France 21.81
Insulatard Penfills 5 X 3ml Penfills Insulin Isophane 100 iu Novo Nordisk A/S (Bagsvaerd) 19.47
Insuman basal Cartridge 5 X 3ml Suspension Recombinant Human Insulin 100 IU/ml Aventis Pharma 24.41

32
Table 9. FDCs of inhalers for asthma or COPD with patient pricing – (median patient price of 26.73 JD [range 4.22,
47.53])
*Highlighted cells indicate SABAs to differentiate from LABAs **Innovator brands (majority) are denoted in bold
Patient
Name Brand No. Doses Dosage Ingredient/Generic Name Manufacturer Price (JD)
Beclomethasone Dipropionate 100 mcg, Formoterol Fumarate
Foster 120 Solution Dihydrate 6 mcg Chiesi pharmaceutici SPA 22.65
Symbicort Turbuhaler 60 Turbuhaler Budesonide 160 mcg, Formoterol Fumarate Dihydrate 4.5 mcg AstraZeneca 21.83
Symbicort Turbuhaler 120 Turbuhaler Budesonide 160 mcg, Formoterol Fumarate Dihydrate 4.5 mcg AstraZeneca 42.37
Symbicort Turbuhaler 60 Turbuhaler Budesonide 320 mcg, Formoterol Fumarate Dihydrate 9 mcg AstraZeneca 39.54
Seretide Evohaler 120 Inhaler Fluticasone 250 mcg, Salmeterol 25 mcg Glaxo Wellcome 42.42
Inhalation Glaxo Wellcome
Relvar Ellipta 30 powder* Fluticasone Furoate 200 mcg, Vilanterol 25 mcg Operations/Ware 38.37
Seretide Diskus 60 Diskus Fluticasone Propionate 100 mcg, Salmeterol (as xinafoate) 50 mcg Glaxo Operations UK Ltd 25.53
Seretide Diskus 60 Diskus Fluticasone Propionate 250 mcg, Salmeterol (as xinafoate) 50 mcg Glaxo Wellcome 34.85
Seretide Diskus 60 Diskus Fluticasone Propionate 500 mcg, Salmeterol (as xinafoate) 50 mcg Glaxo Operations UK Ltd 47.53
Solution for Boehringer Ingelheim
Atrovent Comp HFA 200 inhaler Ipratropium Bromide 20 mcg, Fenoterol HBr 50 mcg Pharma Gmbh & Co. KG 8.1
Clenil Comp. Spray 200 Inhaler Salbutamol 100 mcg, Beclomethasone Dipropionate 50 mcg Chiesi pharmaceutici SPA 4.22
Ventide Inhaler 200 Inhaler Salbutamol 100 mcg, Beclomethasone Dipropionate 50 mcg Glaxo Wellcome 7.25
Combivent Unit Dose Solution for
Vial 60 X 2.5ml inhaler Salbutamol Sulfate 3 mg, Ipratropium Bromide 500 mcg Laboratoire Unither 27.93
Combivent Unit Dose Solution for
Vial 20 X 2.5ml inhaler Salbutamol Sulfate 3.01 , Ipratropium Bromide anhydrous 500 mcg Laboratoire Unither 9.9
Seretide Evohaler 120 Aerosol Salmeterol 25 mcg, Fluticasone Propionate 125 mcg Glaxo Wellcome 32.15
Seretide Evohaler 120 Aerosol Salmeterol 25 mcg, Fluticasone Propionate 50 mcg Glaxo Wellcome 22.77

Table 10. SSRIs by drug concentrate and median unit drug price
*Innovator brands are denoted in bold ** Prices without a range reflect only one product registered
Median unit price [range]
Ingredient/Generic Name Name Brand Dosage Drug Concentrate (JD)
Citalopram Tablet 20 mg 0.3622 [0.3209, 0.4457]
Citalopram Tablet 40 mg 0.5742 [0.5333, 0.85]
Duloxetine Cymbalta Capsules 60 (as hydrochloride) mg 0.6914
Duloxetine Hard gelatin capsule 60 mg 0.8517
Escitalopram (Oxalate) Film-coated tablet 5 mg 0.2490
Escitalopram Tablet 10 mg 0.476 [0.2768, 0.51]
Escitalopram (Oxalate) Tablet 15 mg 0.7139 [0.4833, 0.9446]
Escitalopram (Oxalate) Tablet 20 mg 0.6613 [0.5583, 0.75]
Fluoxetine (Hcl) Capsules 20 mg 0.271 [0.2303, 0.34]
Fluvoxamine Maleate Film-coated tablet 50 mg 0.1611
Fluvoxamine Maleate Film-coated tablet 100 mg 0.3143
Paroxetine Seroxat CR Tablet 12.5 mg 0.4487
Paroxetine Seroxat Tablet 20 mg 0.4938
Paroxetine Tablet 20 mg 0.1315
Paroxetine Film-coated tablet 40 mg 0.2465
Sertraline (Hcl) Film-coated tablet 50 mg 0.1812 [0.1763, 0.258]
Sertraline ZOLOFT Tablet 50 mg 0.2347
Sertraline (Hcl) Tablet 100 mg 0.414 [0.289,0.425]

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Table 11. Public sector median price ratio (MPR) by drug class (or specific drug given data availability)
*Ratio is the median unit price procured by the JPD/ international standard buyer median unit price (International
Medical Products Price Guide, 2015)
**Single items denoted with median prices only
MPR (IQR)
Hypertension or CVD; n=25
ACEIs (n=5) Enalapril, captopril 1.38 (1.11, 1.49)
β-blockers (n=8) Atenolol, bisoprolol, carvedilol, metoprolol, 1.45 (0.78, 2.34)
propranolol
CCBs (n=6) Amlodipine, diltiazem, nifedipine, verapamil 1.88 (0.71, 3.95)
⬧ Amlodipine 5mg ONLY 0.93
Anti-platelet aggregate Acetylsalicylic acid 100 mg (aspirin) 1.41
Anticoagulant (n=2) Warfarin 1.21 (1.19, 1.23)
Statins (n=3) Atorvastatin, simvastatin 0.59 (0.52, 0.90)
Diabetes; n=11
Sulfonylureas (n=5) Glibenclamide, gliclazide, glimepiride 1.33 (0.96, 2.05)
(n=2) Metformin 0.83 (0.76, 0.89)
Insulin (n=4) ⬧ Insulin Human 100 IU/mL R (n=2) 0.52 (0.47, 0.57)
⬧ Insulin Isophane (rDNA Origin) 100 IU/mL 0.58
⬧ Insulin Human 30 IU/mL, Insulin Isophane 70 0.82
IU/mL -mixed
Asthma or COPD; n=5
Inhaled steroid (n=2) Beclomethasone dipropionate 250 mcg, 2.57 (2.29, 2.85)
Budesonide 200 mcg
SABA (inhalation only) Salbutamol (as sulphate) 0.5 % solution & 100 1.13 (0.82, 1.44)
(n=2) mcg aerosol
Bronchodilator Ipratropium bromide anhydrous 20 mcg/puff 1.51
Epilepsy; n=12
(n=4) Carbamazepine 0.83 (0.61, 1.09)
Valproic acid 200mg 0.24
(n=3) Lamotrigine 1.91 (1.19, 2.35)
Phenobarbital 30mg 2.14
Phenytoin 100mg 1.70
(n=2) Topiramate 2.91 (2.43, 3.39)
Psychiatric illnesses; n=3
Tricyclic anti-depressants Amitriptyline, imipramine 1.11 (0.96, 1.40)
(TCAs) (n=3)

34
Table 12. Affordability of generic and brand (originator) medicines in the private sector for predominant diseases
by drug class (% represent share of total drugs registered, n=1155)
*Pricing data unavailable for one product
** Numbers in bold indicate affordability (≤1 days’ wage)
Drug class Number days’ wage - generic Number days’ wage -
(median; IQR) originator (median, IQR)
Hypertension or CVD; n=323 (28%)
ACEIs (n=85*) 1.04 (0.71, 1.23) (n=73) 0.98 (0.86, 1.55) (n=12)
ARBs (n=54*) 1.05 (0.90, 1.25) (n=44) 1.39 (1.28, 2.20) (n=10)
(β)-blockers (n=59) 0.58 (0.40, 0.94) (n=51) 0.72 (0.59, 0.79) (n=8)
Diuretics (n=31) 0.38 (0.32, 0.70) (n=26) 0.50 (0.44, 0.74) (n=5)
Statins (n=94) 2.48 (2.00, 3.64) (n=84) 2.59 (1.65, 3.41) (n=10)
Diabetes; n=144 (12.5%)
Sulfonylureas (n=67) 0.39 (0.24, 0.57) (n=59) 0.60 (0.40, 0.74) (n=8)
Metformin (n=40) 0.41 (0.31, 0.54) (n=37) 0.62 (0.50, 0.80) (n=3)
Based on up Insulin fast-acting (n=14) 1.17 (1.09, 1.30) (n=5) 2.44 (1.85, 2.96) (n=9)
to 30 Insulin long-acting (n=11) 1.27 (1.14, 1.58) (n=4) 1.98 (1.67, 5.55) (n=7)
units/day Insulin mixed (n=12) 1.36 (1.30, 2.22) (n=5) 1.98 (1.67, 2.53) (n=7)
Asthma or COPD; n=45 (3.9%)
Steroid (inhaled) (n=16) 0.32 (0.32, 0.33) (n=2) 1.81 (1.13, 2.65) (n=14)
SABA or LABA (n=16) 1.59 (1.29, 2.02) (n=3) 2.48 (0.74, 3.55) (n=13)
SABA or LABA + steroid (n=13) 1.98 (1.42, 2.53) (n=2) 5.23 (3.93, 5.78) (n=11)

35
Table 13. Unaffordable medications in the public sector based on standard monthly dosing regimen
*Unaffordability defined by > 1 days’ wage for 30-day supply of medicine
No Days'
Drug class/indication Drug name and dosage Dosing regimen Wage
Rivaroxaban 15 mg or 20 mg Once daily 8.0
Anticoagulant or Dabigatran Etexilate 75 mg Twice daily 7.7
Antiplatelet/CVD Dabigatran Etexilate 150 mg Twice daily 7.1
Ticagrelor 90 mg Twice daily 6.4
Candesartan Cilexetil 16 mg, HCTZ 12.5 mg Once daily 1.7
ARB/diuretic/Hypertension
Candesartan Cilexetil 8 mg, HCTZ 12.5 mg Once daily 1.3
Nifedipine 30 mg Once daily 1.2
Verapamil Hcl 80 mg Three times daily 2.0
Antiarrhythmic/CVD Flecainide 100 mg Twice daily 1.4
Fluvoxamine Maleate 100 mg Once daily 1.3
SSRI/Depression
Paroxetine 12.5 mg Once daily 1.5
Twice daily [75 tablets;
Topiramate 25 mg 3.5mg/kg*10kg] 1.4
Twice daily [60 tablets;
Topiramate 50 mg 3.5mg/kg*15kg] 2.7
Antiepileptic/seizures Topiramate 100 mg Once daily [if taken alone] 2.3
Twice daily [180 capsules;
Valproic Acid 150 mg 20mg/kg*45kg] 1.1
Twice daily [180 capsules; 20-
Valproic Acid 300 mg 30mg/kg*60-90kg] 1.5
Meglitinide/Diabetes Repaglinide 2 mg Twice daily 1.3
Saxagliptin 2.5 mg Once daily 1.5
Saxagliptin 5 mg Once daily 1.8
DPP-4 inhibitor/Diabetes
Sitagliptin 100 mg Once daily 2.7
Vildagliptin 50 mg Twice daily 1.5
Three times daily [5-10 IU/ 3*3mL
Insulin Aspart 100 IU/mL Penfil/Flexpen] 2.5
Three times daily [up to 10 IU/
Insulin/Diabetes
Insulin Lispro 100 IU/mL (Humalog Mix 50/50) 3*3mL Cart] 2.0
Insulins & Analogues, Intermediate-Fast Twice daily [up to 15 IU/3*3mL
Combin 70/30 IU/mL, Insulin Aspart penfill cart] 2.3
Budesonide 0.5 mg/ml (Pulmicort suspension) Oncepuff
One daily [30*2mL
twice daily vial]
[60 dose 4.9
Steroid/Asthma Mometasone Furoate 200 mcg inhaler]
One puff twice daily [60 dose 2.6
Mometasone Furoate 400 mcg inhaler] 3.4
LABA/COPD Indacaterol 150 mcg or 300 mcg Once daily 2.2
Tiotropium 18 mcg Once daily 4.0
Bronchodilator/COPD Glycopyronium Bromide inhaler powder hard
capsule 50 mcg Once daily 4.1
SABA/bronchodilator/COP Salbutamol Sulfate 3 mg, Ipratropium Bromide
D 500 mcg/unit dose Three times daily [2.5mL vial] 4.1
Budesonide 160 mcg, Formoterol Fumarate Two puffs twice daily [2*60-dose
LABA/steroid/Asthma Dihydrate 4.5 mcg/dose inhaler] 3.1
Fluticasone Propionate 100 mcg, Salmeterol (as One puff twice daily [60 dose
xinafoate) 50 mcg inhaler] 1.4
Fluticasone Propionate 250 mcg, Salmeterol (as One puff twice daily [60 dose
Steroid/LABA/Asthma
xinafoate) 50 mcg inhaler] 1.8
Fluticasone Propionate 500 mcg, Salmeterol (as One puff twice daily [60 dose
xinafoate) 50 mcg inhaler] 2.5

36
Table 14. Affordability comparison of essential medicines between private and public sectors based on number of
days’ wage metric
*Numbers in bold indicate unaffordability defined by > 1 days’ wage
Private Sector Public Sector
No. days'
wage -
Lowest No. days'
price wage - No. days'
Drug class/indication Drug name and dosage Dosing regimen generic Originator wage

βblocker/hypertension Bisoprolol Fumarate 5mg Once daily 0.4 0.6 0.04

ACEI/hypertension Enalapril Maleate 10mg Once daily 0.6 0.04
ARB/hypertension Valsartan 160mg Once daily 1.1 1.5 0.09

Diuretic/hypertension Hydrochlorothiazide 25mg Once daily 0.3 0.4 0.05

CCB/hypertension Amlodipine 5mg Once daily 0.6 0.9 0.02

Statin/CVD Atorvastatin 40mg Once daily 3.3 4.7 0.12
Antiepileptic/seizures Levetiracetam 500mg Twice daily 2.9 4.1 0.40
Up to 15 units twice
Insulin/Diabetes Insulin 70/30 10 mL vial daily 1.2 1.5 0.20
Sulfonylurea/Diabetes Glimepiride 2mg Once daily 0.3 0.4 0.03

Antihyperglycemic/Diabetes Metformin 850mg Twice daily 0.2 0.6 0.08

Salmeterol 50mcg/Fluticasone
LABA/steroid/Asthma 250mcg One puff twice daily 4.8 1.76
Atypical
antipsychotic/Psychosis Risperidone 4mg Once daily 2.8 3.8 0.08
SSRI/Depression Citalopram 40mg Once daily 2.9 0.11
ARB/diuretic/Hypertension Candesartan 16mg/HCTZ 12.5mg Once daily 0.6 3.4 1.74
ARB/diuretic/Hypertension Valsartan 160mg/HCTZ 12.5mg Once daily 0.8 1.5 0.11

37