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Related post: taxes? How much of what it raises does it spend on health Ramipril Tablet care (versus everything Buy Cheap Ramipril else), and how much of that Ramipril 25 is available for medicines? (Tandon and Cashin 2010). Especially in low-income countries, needs are great and resources are limited; tax bases are small and collection processes are highly imperfect. Because citizens are often willing to pay out of pocket for pharmaceuticals, it is tempting for governments to allow them to do so. That is especially so because governments often ??nd it difficult to ensure that medicines are available in public facilities, especially in the periphery. The Ramipril Mg problems of purchasing, distribution, and theft prevention, along with limited capital, are so great that citizens frequently become dissatis??ed with the lack of sup- plies in public facilities. As a result, in many low-income countries we see the paradoxical situation that although medicines Ramipril 5mg are among the most effec- tive forms of health Ramipril 10mg expenditure and one that citizens care about greatly they are also an area that governments heavily underfund, so that the greatest part of spending on medicines is left to private, out-of-pocket pur- chase (as noted in chapter 1). Sometimes it is possible to change the funding for medicines without changing health sector ??nancing generally (for example, the revolving drug funds supported by the Bamako Initiative). But more usually, the creation of a new insurance scheme or the development of a new tax source involves changes in funding for health sector activities outside of pharmaceuticals. Often it requires the mobilization of a signi??cant support coalition and can lead to complex political negotiations. 102 Ramipril Tablets Pharmaceutical Reform In low-income countries, pharmaceutical funding is also entangled with health sector funding through the decision-making processes of donors. Multilateral and bilateral donors that support medicines purchases also often support the health What Is Ramipril sector generally. So if they spend more on medi- cines, they may spend less on other health activities and vice versa. Such nonmedicines health funding (and even nonhealth donor support) Order Ramipril Online can, in principle, free local resources for pharmaceutical purchasing. The Order Ramipril question is, How do governments choose to use the ??scal space that aid helps to cre- ate? At the same time, the conditions tied to donor support can limit the ability of governments to allocate funds to ??t their own priorities. In recent years we have seen a major increase in donor ??nancial aid for medicines for speci??c diseases (for example, the Global Fund to Fight AIDS, TB, and Malaria; the Global Alliance for Vaccines and Immunization [GAVI]; and the President�s Emergency Plan for AIDS Relief [PEPFAR]). Direct donations by manufacturers of drugs for other diseases (such as onchocer- ciasis, schistosomiasis, and trachoma) have also increased. But these dona- tions are limited in the number of diseases covered and often in the scope of coverage. (For a list of medicine programs supported by pharmaceutical companies, see http://www.globalhealthprogress.org.) As a result, host country funding almost always plays some role in pharmaceutical policy, and it is often the rate-limiting constraint on the scope and composition of public sector activity. Judging the Distributional Impact of Financing Options Economists have a particular framework for judging Ramipril 2 Mg the distributional impact of ??nancing options. They start from a reference point at which all individuals (or families) pay the same fraction of their income to support an activity. Such a burden is said to be �proportional.?? A ??nancing system in which upper-income people pay a higher proportion of their income is called �progressive,?? and one in which lower-income people pay a higher proportion of their income is �regressive.?? Reformers who care most about increasing equity tend to favor ??nancing systems that are progressive. However, even a regressive system can involve higher absolute (albeit lower proportional) burdens on upper-income households. Hence Ramipril 25 Mg the combined impact of a regressive ??nancing system (provided it is not too regressive) and a pro-poor distribution of bene??ts (provided it is sufficiently pro-poor) can, on balance, be redistributive in favor of lower-income groups. Financing the Pharmaceutical Sector 103 Financing Options We propose a six-way typology to describe the major options for ??nancing a nation�s health system and its pharmaceutical sector. General Tax Revenue Almost all nations rely to some extent on general tax revenue for ??nancing pharmaceutical purchases. Which taxes are levied depends on a country�s level of economic development. The lowest-income countries, with the smallest formal business sectors, often rely heavily on import duties. The number of possible ports Ramipril 10 Mg of entry (through which signi??cant quantities of goods can move) is generally sufficiently limited to make enforcement pos- sible. If countries are lucky enough to have minerals, signi??cant commodity exports, or tourist industries, those too are often taxed. Like taxes on imports, taxes on exports are indirect. Indirect taxes are not directly paid by workers or consumers, but rather by nonretail busi- nesses, and that can make them politically attractive. In practice, however, import duties generally result in higher prices for imported goods. That is one reason why they are often levied at higher rates on luxury goods, such as imported vehicles and Tablet Ramipril imported alcoholic beverages. Export fees are often borne by local Ramipril Online producers in the form of Ramipril Price lower net incomes, inasmuch as they typically have to meet world prices for their exports. Once countries attain even a modest level of development, sales and value- added taxes are commonly used. They are easier to implement than taxes on individuals because there are fewer sellers than buyers and hence fewer points of collection. A similar logic applies to certain kinds of business taxes. The conventional wisdom in industrialized economies is that sales and value- added taxes are regressive. Upper-income individuals save a higher propor- tion of their incomes, and income that is saved escapes such taxes. In low- and middle-income countries, however, a good deal of economic activity escapes all taxation, for example, subsistence farming and cash transactions in the informal sector. Because a higher percentage of the con- sumption of upper-income individuals is likely to be subject to tax, the pro- gressivity of retail taxes is increased. That progressivity has been an important consideration in countries, such as Ghana and Colombia, that have chosen to ??nance Ramipril Cough social insurance systems for low-income individuals through retail taxes and have used the proceeds in Buy Ramipril Online part to provide low-cost medicines in the public sector. Historically, many low- and middle-income countries have exempted certain commodities from sales taxes. They have even provided subsidies to keep certain prices low in the name of redistributive goals and to Buy Ramipril increase the political popularity of the regime (bread, rice, gasoline, or housing, 104 Pharmaceutical Reform depending on the country). Conversely, in many countries some luxury goods are subject to higher sales tax rates (including jewelry, restaurant meals, and automobiles). The key concept in those schemes is what economists call the �income elasticity of demand.?? In particular, Cheap Ramipril how does the percentage of income spent on a certain good vary with income? When that percentage rises with income, a tax on the good in question is progressive. When the percentage
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