Tài liệu Medicine prices and pricing policies in vietnam

MEDICINE PRICES AND PRICING POLICIES IN VIETNAM Tuan Anh Nguyen A thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy School of Public Health & Community Medicine Faculty of Medicine, University of New South Wales, Australia April 2011 THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Nguyen First name: Tuan Anh Other name/s: Abbreviation for degree as given in the University calendar: PhD School: Public Health and Community Medicine Faculty: Medicine Title: Medicine prices and pricing policies in Vietnam Abstract 350 words maximum: Availability of affordable medicines is one precondition to realizing the fundamental human right of access to essential healthcare. Although Vietnam is progressing well with several health-related targets of the Millennium Development Goals being achieved ahead of time, attaining equitable access to affordable medicines remains problematic. In this thesis, a mixed-method approach was adopted in the analysis of medicine prices and polices. The literature was reviewed, followed by an analysis of Vietnam‘s pharmaceutical market and legislation. A quantitative study of medicine prices, and a qualitative study on how and why high, unaffordable prices occurred, were conducted. The findings were synthesized to form policy recommendations. The studies demonstrated that medicine prices in Vietnam were unreasonably high. Adjusted for Purchasing Power Parity in 2005, prices in the public sector were 46.58 times the international reference price for innovator-brand medicines and 11.41 times for the lowest-priced generic equivalents. Monopoly of supply was an important cause of high innovator-brand prices. More complex, intrinsic features of Vietnam‘s healthcare system were also reported by key stakeholders as driving up prices. Economic survival pressures, in an imperfectly competitive market, were said to force both pharmaceutical companies and prescribers to be inextricably linked financially. Ethics and personal values however did influence prescribers‘ behaviour and their response to corrupt procedures. Overall, intractable, systemic features contributing to high prices included unrealistic low salaries for prescribers, poor economies of scale in domestic production, inefficiencies in the local distribution network, malfunctioning pricing policies and a general lack of transparency and accountability in administrative procedures. A range of policy measures and changes are required to improve access to medicines in Vietnam. Shortterm recommendations include amendments to pharmaceutical policies, with better enforcement of current regulations. Medium-term measures include the public health insurance system taking an active role in price setting, pooling procurement through a national tendering procurement system and reform of the domestic market through rationalization with appropriate capital and technological investment to achieve improved efficiencies and economies of scale. Longer-term goals include health system improvements to address poor governance, low remuneration of prescribers, with additional measures to limit the scope for corrupt practices. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350-word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). ...........................………................. .......................………………..... ……………………...…….… Signature Witness Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. Date of completion of requirements for Award: FOR OFFICE USE ONLY THIS SHEET IS TO BE GLUED TO THE INSIDE FRONT COVER OF THE THESIS ORIGINALITY STATEMENT ‗I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.‘ Signed.................................................................................... Date....................................................................................... COPYRIGHT STATEMENT ‗I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.' Signed ……………………………………………........................... Date ……………………………………………........................... AUTHENTICITY STATEMENT ‗I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.‘ Signed ……………………………………………........................... Date ……………………… …………………………………….. ii DEDICATION This thesis is dedicated to my parents, Dinh Thiem Nguyen and Thi Lien Doan, for nurturing me and teaching me to care about others. iii iv ACKNOWLEDGEMENTS I would like to thank the Ministry of Education and Training of Vietnam, Vietnam government for awarding me a PhD scholarship to study in Australia. I would also like to acknowledge the Vietnam team who conducted the survey of medicine prices and availability, and the Ministry of Health of Vietnam for giving me permission to use the survey data in this thesis. I am grateful to all members of the Drug Price Management Division, Drug Administration of Vietnam for sharing their views as well as their cooperation and support when I conducted fieldwork in Vietnam. My project also rests on the cooperation, generosity and courage of the sixty study participants who gave their time and shared their valuable opinions and sensitive information in the interviews. I owe a debt of gratitude to my supervisor, Associate Professor Rosemary Knight. Without her mentorship, support, and depth of knowledge, this thesis would not have been completed. Her calm, insights, compassion and elegant language were central to the conceptualisation, design, analysis and reporting of this thesis, as was her vision and ability to approach problems from a global perspective. My co-supervisors, Associate Professor Andrea Mant and Dr. Quang Minh Cao were patient, thoughtful and encouraging. Their critical comments and feedback were invaluable along every step of this project. Their practical and consistent support has kept me going to the end of my PhD journey. Dr. Husna Razee was my qualitative co-supervisor, whose experience and knowledge in qualitative research greatly contributed to the qualitative study for this thesis. My special thanks go to Dr. Geoffrey Brooks for sharing his excellent knowledge of economics and Australian pharmaceutical policy and practice, and for taking me under his wing as my second father. His critical feedback greatly improved the quality of this thesis. Support was also received from Dr. Pat Bazeley who assisted me in developing the qualitative coding schemes, steered me through the perils of NVIVO and mixed methods research and fed me from her research farm. v I am grateful to Mr. Martin Auton (Global project officer - Pricing, Health Action International Global) and Ms. Alexandra Cameron (Coordinator medicine pricing project, WHO) for their cross-analysis of the survey data and for giving me valuable comments on the quantitative study for this thesis. Great thanks are also due to Mr. Wayne Critchley (Former Executive Director, Patented Medicine Prices Review Board Government of Canada) for providing critical feedback on the policy analysis components of the thesis. My colleagues in the School of Public Health and Community Medicine at UNSW also provided great ideas and valuable comments, including Mr. Kevin Forde, Dr. Niahm Stephenson, Dr. Ilse Blignault, Dr. Brahmaputra Marjadi, and Dr. Joanne Spangaro. I would like to thank my former supervisor, Associate Professor Tessa Ho, for her warm encouragement and caring, even when she was not able to supervise me due to her move to another university. Sincere thanks to my fellow PhD students who shared with me both my frustration and happiness, especially Dr. Keith Masnick. My wife Thu Ha Dang, my daughter Thanh Mai Nguyen and my son Dang Nhat Minh Nguyen are my life. Without their love, encouragement and support, I would not have had the strength and determination to pursue my dream. vi TABLE OF CONTENTS DEDICATION ............................................................................................................... III ACKNOWLEDGEMENTS ............................................................................................. V LIST OF PUBLICATIONS ARISING FROM THIS RESEARCH ............................XIV LIST OF TABLES ........................................................................................................ XV LIST OF FIGURES ................................................................................................... XVII GLOSSARY/ACRONYMS ..................................................................................... XVIII ABSTRACT .................................................................................................................. XX CHAPTER 1. INTRODUCTION .................................................................................. 1 1.1 BACKGROUND ........................................................................................................ 1 1.2 AIM AND OBJECTIVES ........................................................................................... 3 1.3 RESEARCH DESIGN AND METHODOLOGICAL CONSIDERATIONS ............ 5 1.3.1 Overall research design ........................................................................................... 5 1.3.2 The rationale for a mixed methods approach ........................................................... 6 1.3.3 Researcher background and orientation to the study ............................................... 6 1.3.4 Currency used in this thesis ..................................................................................... 7 1.4 FLOW OF RESEARCH AND INTERCONNECTION OF CHAPTERS ................. 8 CHAPTER 2. MEDICINE PRICES, PRICING POLICIES AND PATIENT ACCESS: A REVIEW OF THE INTERNATIONAL LITERATURE ................... 11 2.1 INTRODUCTION .................................................................................................... 11 2.2 NATIONAL MEDICINES POLICIES AND ACCESS TO MEDICINES .............. 12 2.2.1 Rational selection and use of essential medicines.................................................. 14 2.2.2 Sustainable financing ............................................................................................. 15 2.2.3 Reliable health and supply systems........................................................................ 16 2.2.4 Affordable prices .................................................................................................... 17 2.3 MEDICINE PRICES AND THEIR DETERMINANTS .......................................... 18 2.3.1 The pharmaceutical market .................................................................................... 18 2.3.1.1 A market with unique features ........................................................................ 18 2.3.1.2 A market with conflicting objectives .............................................................. 19 2.3.1.3 A heterogeneous market .................................................................................. 20 2.3.2 Pharmaceutical expenditure ................................................................................... 22 vii 2.3.3 The determinants of medicine consumption .......................................................... 22 2.3.3.1 Physicians‘ prescribing behaviour .................................................................. 23 2.3.3.2 Patient demand ................................................................................................ 24 2.3.4 The determinants of medicine prices ..................................................................... 25 2.3.4.1 The costs of research and development, manufacturing and marketing ......... 26 2.3.4.2 Degree of market competition......................................................................... 28 2.3.4.3 Pharmaceutical market intelligence ................................................................ 30 2.3.4.4 Market size and economies of scale ................................................................ 30 2.4. POLICY OPTIONS FOR COST CONTAINMENT OF MEDICINES .................. 30 2.4.1 Overview of price controls ..................................................................................... 30 2.4.1.1 External price benchmarking .......................................................................... 33 2.4.1.2 Internal reference pricing ................................................................................ 35 2.4.1.3 Cost plus pricing ............................................................................................. 36 2.4.1.4 Pharmaco-economic evaluation ...................................................................... 37 2.4.1.5 Price negotiations ............................................................................................ 39 2.4.1.6 Profit ceilings .................................................................................................. 39 2.4.2 Price controls along the supply chain .................................................................... 40 2.4.2.1 Price controls at ex manufacturer/ex importer level ....................................... 40 2.4.2.2 Price controls at wholesale and pharmacy retail level .................................... 41 2.4.3 Reimbursement measures ...................................................................................... 42 2.4.3.1 Positive list or formulary systems ................................................................... 43 2.4.3.2 Reference price systems .................................................................................. 44 2.4.3.3 Index pricing systems...................................................................................... 46 2.4.3.4 Co-payments ................................................................................................... 46 2.4.3.5 Generic substitution ........................................................................................ 49 2.4.3.6 Other measures influencing demand ............................................................... 50 2.4.4 Evaluation of pricing and reimbursement policies ................................................ 51 2.5 STUDIES ON MEDICINE PRICES IN DEVELOPING COUNTRIES ................. 53 2.5.1 International studies ............................................................................................... 53 2.5.2 Vietnam studies ...................................................................................................... 56 2.5.3 Conclusions ............................................................................................................ 60 CHAPTER 3. VIETNAM’S HEALTH CARE AND PHARMACEUTICAL SYSTEM, AND ITS IMPACT ON MEDICINE PRICES ........................................ 63 viii 3.1 INTRODUCTION .................................................................................................... 63 3.2 VIETNAM‘S TRANSITIONAL HEALTH CARE SYSTEM ................................. 63 3.2.1 Vietnam‘s health performance ............................................................................... 63 3.2.2 Historical background ............................................................................................ 64 3.2.3 The ―Doi Moi‖ economic reforms ......................................................................... 64 3.2.4 Health insurance and subsidization for the poor .................................................... 65 3.2.5 National Medicines Policy ..................................................................................... 66 3.2.6 Administrative health care structures ..................................................................... 67 3.2.7 An emerging private health sector ......................................................................... 69 3.3 DEMAND FOR MEDICINES .................................................................................. 70 3.3.1 Epidemiological patterns and lifestyle changes ..................................................... 70 3.3.2 Health care financing ............................................................................................. 71 3.3.3 Use of medicines .................................................................................................... 73 3.4 SUPPLY OF MEDICINES ....................................................................................... 74 3.4.1 Importation of medicines ....................................................................................... 75 3.4.2 Domestic medicine production .............................................................................. 76 3.4.3 Medicine distribution ............................................................................................. 79 3.4.3.1 Vietnam‘s pharmaceutical importers .............................................................. 81 3.4.3.2 International pharmaceutical distributors and their foreign direct investment logistics companies ..................................................................................................... 82 3.4.3.3 Private pharmaceutical wholesalers and distributors ...................................... 82 3.4.3.4 Retail medicine outlets and hospital pharmacies ............................................ 83 3.4.3.5 Hospital tender procedures and practices ........................................................ 85 3.4.3.6 Supply of medicines by medical practitioners ................................................ 86 3.5 IMPLICATIONS FOR MEDICINE PRICES ........................................................... 86 3.5.1 Ineffective governance ........................................................................................... 87 3.5.2 A poorly organized and internationally dependent market .................................... 87 3.5.3 Market imperfections ............................................................................................. 88 3.5.4 The role of public health insurance in containing medicine prices ........................ 89 3.6 CONCLUSIONS ....................................................................................................... 90 CHAPTER 4. AVAILABILITY AND AFFORDABILITY OF MEDICINES IN VIETNAM ..................................................................................................................... 93 4.1 INTRODUCTION .................................................................................................... 93 ix 4. 2 METHODS .............................................................................................................. 93 4.2.1 Sampling ................................................................................................................ 93 4.2.2 Medicines surveyed................................................................................................ 94 4.2.3 Data collection and entry ....................................................................................... 96 4.2.4 Data analysis .......................................................................................................... 96 4.3 RESULTS ................................................................................................................. 98 4.3.1 Medicine availability.............................................................................................. 99 4.3.2 Medicine prices ...................................................................................................... 99 4.3.3 Affordability......................................................................................................... 101 4.3.4 Variation across regions ....................................................................................... 102 4.3.5 International comparison...................................................................................... 103 4.3.5.1. Medicine availability.................................................................................... 103 4.3.5.2. Medicine prices ............................................................................................ 104 4.3.5.3 Affordability.................................................................................................. 107 4.4 DISCUSSION ......................................................................................................... 107 4.5 CONCLUSIONS ..................................................................................................... 111 CHAPTER 5. MEDICINE PRICING POLICIES IN VIETNAM ......................... 113 5.1 INTRODUCTION .................................................................................................. 113 5.2 METHODS ............................................................................................................. 113 5.3 RESULTS ............................................................................................................... 114 5.3.1 Context of medicine pricing regulations in Vietnam ........................................... 116 5.3.2 The price declaration and publication of medicine pricing policies .................... 118 5.3.2.1. The reasonableness of declared prices and published prices ....................... 118 5.3.2.2 Other declaration and publication provisions ............................................... 121 5.3.3 Other pricing provisions....................................................................................... 122 5.4 DISCUSSION ......................................................................................................... 123 5.4.1 The reasonableness of declared prices and published prices ............................... 123 5.4.2 Declaration and publication provisions................................................................ 125 5.5 RECOMMENDATIONS ........................................................................................ 127 5.6 CONCLUSIONS ..................................................................................................... 128 CHAPTER 6. ROOT CAUSES OF HIGH MEDICINE PRICES IN VIETNAM 129 6.1 INTRODUCTION .................................................................................................. 129 6.2 METHODS ............................................................................................................. 129 x 6.2.1 Method selection .................................................................................................. 129 6.2.2 Participant recruitment ......................................................................................... 130 6.2.3 Interview instruments ........................................................................................... 131 6.2.4 Ethical issues ........................................................................................................ 134 6.2.5 Data collection and analysis ................................................................................. 135 6.2.5.1 Data collection .............................................................................................. 135 6.2.5.2 Data analysis ................................................................................................. 136 6.2.6 Data presentation .................................................................................................. 137 6.3 RESULTS ............................................................................................................... 138 6.3.1 Participant characteristics..................................................................................... 138 6.3.2 Factors influencing medicine prices..................................................................... 139 6.3.2.1 Patent and monopoly ..................................................................................... 139 6.3.2.2 Market intelligence ....................................................................................... 140 6.3.2.3 Market size and economies of scale .............................................................. 140 6.3.2.4 Source and quality of medicines ................................................................... 141 6.3.2.5 Informal payments ........................................................................................ 142 6.3.2.6 Other components of the final price of medicines ........................................ 144 6.3.2.7 Ineffective control by government ................................................................ 146 6.4 DISCUSSION ......................................................................................................... 147 CHAPTER 7. WHY AND HOW INFORMAL PAYMENTS OCCUR ................. 151 7.1 INTRODUCTION .................................................................................................. 151 7.2 OPPORTUNITY FOR CORRUPTION .................................................................. 151 7.2.1 Discretion ............................................................................................................. 152 7.2.2 Transparency ........................................................................................................ 153 7.2.3 Accountability ...................................................................................................... 155 7.2.4 Enforcement ......................................................................................................... 157 7.3 PRESSURES FOR CORRUPTION ....................................................................... 160 7.3.1 Pharmaceutical market related factors ................................................................. 160 7.3.1.1 Product related factors................................................................................... 160 7.3.1.2 Sales representatives related factors.............................................................. 162 7.3.1.3 Regulation related factors ............................................................................. 162 7.3.1.4 Survival in the market ................................................................................... 163 7.3.2 Healthcare processes and structures ..................................................................... 166 xi 7.3.2.1 The tender system ......................................................................................... 166 7.3.2.2 The information system ................................................................................ 168 7.3.2.3 The taxation system ...................................................................................... 168 7.3.2.4 The role of the private and public sectors ..................................................... 170 7.3.2.5 Remuneration systems and financial pressure .............................................. 170 7.3.2.6 Workplace pressures ..................................................................................... 172 7.4 RATIONALIZATION OF CORRUPTION ........................................................... 174 7.4.1 The normalization of corruption .......................................................................... 174 7.4.1.1 The prevalence of corrupt practices .............................................................. 174 7.4.1.2 Other social norms ........................................................................................ 175 7.4.2 Self-interest maximization ................................................................................... 176 7.4.2.1 Professional ethics......................................................................................... 176 7.4.2.2 Personal values .............................................................................................. 177 7.4.2.3 Knowledge and skills .................................................................................... 178 7.4.2.4 Advancement opportunity ............................................................................. 178 7.4.2.5 Reputation ..................................................................................................... 179 7.4.2.6 Employment .................................................................................................. 180 7.5 DISCUSSION ......................................................................................................... 180 CHAPTER 8. DISCUSSION AND POLICY RECOMMENDATIONS................ 185 8.1 INTRODUCTION .................................................................................................. 185 8.2 REVIEW OF THE RESEARCH OBJECTIVES .................................................... 185 8.3 SYNTHESIZED RESULTS OF THE RESEARCH .............................................. 187 8.3.1 Vietnam‘s medicine prices and availability problems ......................................... 187 8.3.2 Reasons for unaffordable medicine prices in Vietnam ........................................ 188 8.3.2.1 Selection of medicines .................................................................................. 188 8.3.2.2 Use of medicines ........................................................................................... 188 8.3.2.3 Pharmaceutical pricing regime...................................................................... 189 8.3.2.4 Pharmaceutical procurement system ............................................................. 191 8.3.2.5 Patent and monopoly issues .......................................................................... 192 8.3.2.6 Government taxes and duties ........................................................................ 193 8.3.2.7 Financing ....................................................................................................... 194 8.3.2.8 Pharmaceutical distribution network ............................................................ 194 8.3.2.9 Corrupt Practices ........................................................................................... 198 xii 8.4 POLICY RECOMMENDATIONS......................................................................... 200 8.4.1 Rational selection and use of essential medicines................................................ 200 8.4.1.1 Rational selection .......................................................................................... 200 8.4.1.2 Rational use ................................................................................................... 201 8.4.2 Affordable prices and sustainable financing system ............................................ 201 8.4.2.1 Strengthening the current pricing regime ...................................................... 201 8.4.2.2 Adoption of a national generic medicines policy.......................................... 205 8.4.2.3 Improvement of public sector procurement of medicines............................. 206 8.4.2.4 Reduction or elimination of duties and taxes ................................................ 207 8.4.2.5 Use of WTO/TRIPS flexibility ..................................................................... 207 8.4.3 Supply and distribution system ............................................................................ 208 8.4.4 Systems improvement to minimize the opportunity for corruption ..................... 208 8.5 CONTRIBUTION OF THE THESIS ..................................................................... 210 8.6 CONCLUSION ....................................................................................................... 211 REFERENCES ............................................................................................................ 215 APPENDIX 1: MEDIAN PRICE RATIO OF INDIVIDUAL INNOVATOR BRAND MEDICINES IN THE PUBLIC PROCUREMENT SECTOR, PUBLIC SECTOR, PRIVATE SECTOR, AND OTHER SECTOR (NOT-FOR-PROFIT PUBLIC SECTOR) IN VIETNAM IN 2005 ............................................................................... 239 APPENDIX 2: MEDIAN PRICE RATIO OF INDIVIDUAL LOWEST-PRICED GENERIC MEDICINES IN THE PUBLIC PROCUREMENT SECTOR, PUBLIC SECTOR, PRIVATE SECTOR, AND OTHER SECTOR (NOT-FOR-PROFIT PUBLIC SECTOR) IN VIETNAM IN 2005 ................................................................ 241 APPENDIX 3: MEDICINE PRICING POLICY IN VIETNAM: DOCUMENTARY ANALYSIS FRAMEWORK ........................................................................................ 243 APPENDIX 4: SAFETY AND RISK MANAGEMENT STRATEGY ....................... 246 APPENDIX 5: INFORMED CONSENT...................................................................... 247 xiii LIST OF PUBLICATIONS ARISING FROM THIS RESEARCH Nguyen AT, Knight R, Mant A, Cao QM, Auton M (2009). Medicine prices, availability, and affordability in Vietnam. Southern Med Review, 2 (2): 2-9 (Chapter 4) Nguyen AT, Knight R, Mant A, Cao QM, Brooks G (2010). Medicine pricing policies: Lessons from Vietnam. Southern Med Review, 3 (2): 12-19 (Chapter 5) Nguyen AT, Knight R, Razee H, Mant A, Cao QM (2010). Root causes of high medicine prices in Vietnam – A qualitative study. Pharmacy Practice (Internet), 8 (Suppl.1): 50-51 (Chapter 6 and Chapter 7) xiv LIST OF TABLES Table 2.1 Factors influencing prescribing behaviour by level of analysis..............24 Table 2.2 Prices of 100 tablets of Zantac 150mg in 1998 (in US dollars)..............57 Table 4.1 Basket of 42 medicines surveyed in Vietnam in 2005............................94 Table 4.2 Mean availability and ranges for IBs and LPGs by sectors for 42 medicines surveyed in 2005 in Vietnam.................................................99 Table 4.3 Median price ratio of IBs, LPGs in public procurement sector, public sector, private sector, and other sector (not-for-profit public sector) in Vietnam in 2005.........................................................100 Table 4.4 Median price ratio of IBs, LPGs on the current Essential Medicine List in the public procurement sector, public sector, private sector, and other sector (not-for-profit public sector) in Vietnam in 2005…...101 Table 4.5 Mean percentage availability of individual lowest-priced generic medicines in Vietnam, in comparison with the average of country-level mean percentage availability of individual lowest-priced generic medicines in the WHO Western Pacific Region……………………...104 Table 4.6 Median price ratios of the public procurement prices, public patient prices, private patient prices for LPG medicines, and private patient prices for IBs in Vietnam in comparison with those in the Western Pacific Region in 2004..................................................106 Table 4.7 Number of days‘ wages of the lowest-paid unskilled government worker needed to purchase a course of treatment in Vietnam in comparison with those in the Western Pacific Region in 2004.........107 Table 5.1 Legislative and sub-legislative documents from January 1989 to March 2008 influencing medicine prices in Vietnam...........................115 Table 5.2 Price declaration provided to the Drug Administration of Vietnam by the registrant Company A for medicine X.......................................121 Table 5.3 Summary of preconditions of declaration and publication mechanism used in Vietnam pricing regulations...................................122 xv Table 6.1 Characteristics of participants...............................................................138 Table 7.1 Matrix of intervening factors for corrupt practices in the model..........183 xvi