Child-Specific Medicine Prices, Availability and Affordability in Ghana

Transcription

1 Better medicines for children in Ghana Ministry of Health GHANA Child-Specific Medicine Prices, Availability and Affordability in Ghana Report of a survey conducted September 2010 The Ghana National Drugs Programme (Ministry of Health) P.O. Box MB 582, Accra Ghana Tel /1 Fax Website: gndp@ghndp.org Ghana Project Website: WHO Project Website:

2 World Health Organization 2011 All rights reserved. Publications of the World Health Organization are available on the WHO web site ( or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: ; fax: ; Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press through the WHO web site ( The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.

3 PROJECT TEAM Survey manager Brian Adu Asare, Ghana National Drugs Programme, Ministry of Health, Accra Area supervisors Ralph Johnson, Faculty of Pharmacy, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi Joseph Tsiase, Ridge Hospital Pharmacy Department, Accra Saviour Yevutsy, Pharmacy Unit, Ghana Health Service, Accra Data collectors Akosua Agyeman, Pharmacy Council, Accra Maame Abena Kwane Owusu Ansah, Faculty Of Pharmacy, KNUST, Kumasi Fidelicia Bakobie, Adabraka Polyclinic, Accra Lina Bannerman Hyde, Faculty of Pharmacy, KNUST, Kumasi Edmund Dianbiir, Regional Health Administration Upper West Region, Wa Shelta Genfior, Pharmacy Council, Accra R.K.S. Hadzi, Regional Health Administration Upper West Region, Wa John Klu, Pharmacy Council, Accra Wolarko Klu, Faculty of Pharmacy, KNUST, Kumasi Cyril Dan Lardy, Maamobi Polyclinic, Accra Sarah Quartey, Faculty of Pharmacy, KNUST, Kumasi Zacchi Sabogu, Regional Health Administration Upper West Region, Wa Data entry personnel Karen Interkudzi, Pharmacy Council, Accra Isaac Koduah, Independent Consultant, Accra Report writing Brian Adu Asare, Ghana National Drugs Programme, Ministry of Health Edith Andrews Annan, WHO Country Office for Ghana, Accra Martha Gyansa Lutterodt, Ministry of Health/Ghana Health Service, Accra Administrative coordination Augustina Koduah, Ghana National Drugs Programme, Ministry of Health

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5 TABLE OF CONTENTS ABBREVIATIONS... ERROR! BOOKMARK NOT DEFINED. LIST OF FIGURES AND TABLES... II ACKNOWLEDGEMENTS... III CONFLICT OF INTEREST STATEMENT... III EXECUTIVE SUMMARY... V BACKGROUND... V METHODOLOGY... V KEY RESULTS... VI Availability of medicines in the public and private sector... vi Public sector procurement prices... vi Public sector patient prices... vi Private sector patient prices... vi Affordability of standard treatment regimens... vi CONCLUSIONS... VI RECOMMENDATIONS... VII INTRODUCTION... 1 OBJECTIVES... 2 COUNTRY BACKGROUND... 2 HEALTH SECTOR... 2 PHARMACEUTICAL SECTOR... 3 METHODOLOGY... 5 OVERVIEW... 5 SELECTION OF MEDICINE OUTLETS... 5 SELECTION OF MEDICINES TO BE SURVEYED... 6 DATA COLLECTION... 6 DATA ENTRY... 7 DATA ANALYSIS... 7 RESULTS AVAILABILITY OF MEDICINES ON THE DAY OF DATA COLLECTION PUBLIC SECTOR PRICES PRIVATE SECTOR PATIENT PRICES MISSION SECTOR PATIENT PRICES COMPARISON OF PATIENT PRICES IN THE PUBLIC AND PRIVATE SECTORS AFFORDABILITY OF STANDARD TREATMENT REGIMENS CONCLUSIONS AND RECOMMENDATIONS REFERENCES ANNEX 1. LIST OF MEDICINES SURVEYED ANNEX 2. MEDICINE DATA COLLECTION FORM ANNEX 3. AVAILABILITY OF INDIVIDUAL MEDICINES, PUBLIC, PRIVATE AND MISSION SECTOR ANNEX 4. MEDIAN PRICE RATIOS, PUBLIC SECTOR PROCUREMENT PRICES ANNEX 5. MEDIAN PRICE RATIOS, PUBLIC SECTOR PATIENT PRICES ANNEX 6. MEDIAN PRICE RATIOS, PRIVATE SECTOR PATIENT PRICES Page i

6 LIST OF FIGURES AND TABLES Figure 1: Mean availability of child-specific medicines on the day of data collection; public, private, and mission sectors... 8 Figure 2: Median price ratios for selected child-specific medicines, originator brand and lowest-price generic equivalents, private sector Figure 3: Number of days wages required to treat selected uncomplicated conditions based on standard treatments Table 1. Sample of public, private and mission sector medicine outlets... 6 Table 2: Availability (%) of individual generic medicines by therapeutic class Table 3. Table 4. Table 5. Public sector procurement: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Public sector patient prices: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Median MPRs for medicines found in both public procurement and public sector medicine outlets (final patient prices) Table 6. Ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Table 8. Median MPRs for medicines found in both public and private sectors Table 9. Number of days' wages of the lowest-paid government worker needed to purchase standard treatments from the private sector ABBREVIATIONS CHPS Community based Health Planning and Services DTC Drugs and Therapeutics Committee EML Essential Medicines List FDB Food and Drugs Board GDP Gross domestic product GNDP Ghana National Drugs Programme HAI Health Action International OB Originator brand LPG Lowest priced generic equivalent MPR Median price ratio MSH Management Sciences for Health NEML National Essential Medicines List NHIS National Health Insurance Scheme USD United States dollars (also $) WHO World Health Organization Page ii

7 ACKNOWLEDGEMENTS We are grateful to the Ministry of Health of Ghana for permission to conduct this study. We would like to thank the directors and heads of regional health directorates and heads of private and mission health facilities and medicines outlets who endorsed the study and granted access to facilities in the three survey areas. We are thankful for the cooperation of pharmacists and other staff at the medicine outlets where data collection took place. We also wish to extend our thanks to the Better Medicines for Children (BMC) Ghana Steering Committee Advisory Group. Health Action International (HAI) and the World Health Organization (WHO) provided technical support for the survey and their assistance is gratefully acknowledged. We would also like to thank the following individuals whose assistance was invaluable: Ms Alexandra Meagan Cameron Dr Herman Garden Dr Sue Hill Dr Clive Ondari This survey was conducted with financial support from WHO. Conflict of interest statement None of the authors of this report, nor anyone who had influence on the conduct, analysis or interpretation of the results, has any competing financial or other interests. Page iii

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9 EXECUTIVE SUMMARY Background Reducing child mortality is one of the global priorities expressed in the Millennium Development Goals (Goals 4 and 6). A pre condition to achieve these goals is the availability of essential medicines for children. Mortality rates for infants and children under the age of five are estimated at 50 and 80 per 1000 births, respectively. Most of these deaths are caused by diseases that could be prevented, treated or managed by access to safe, essential childspecific medicines. Child specific medicines are those manufactured to suit the age, physical condition and body weight of a child. A field study to measure the price, availability and affordability of selected child specific medicines was undertaken in Ghana from August to October 2010, using a standardized methodology developed by the World Health Organization (WHO) and Health Action International (HAI). This survey had the following objectives: measure the availability of child specific medicines in Ghana; evaluate and compare prices of child specific medicines in the public, private and mission sectors to government procurement prices; evaluate the affordability of child specific medicines in Ghana. Methodology The survey of medicine prices and availability was conducted in three regions, namely: survey area 1 (Greater Accra Region); survey area 2 (Ashanti Region); and survey area 3 (Upper West Region). Data on 30 child specific medicines (38 formulations) were collected in 18 public and 42 private sector medicine outlets (including four mission drug outlets). The tracer medicines list used in this assessment was based on WHO recommendations and local country needs. Data was also collected on government procurement prices for the selected medicines. For each medicine in the survey, data was collected for the originator brand and lowest priced generic equivalent (i.e. generic product with the lowest price at each facility). Medicine prices are expressed as ratios relative to Management Sciences for Health international reference prices for 2009 (median price ratio, or MPR). Using the salary of the lowest paid unskilled government worker, affordability was calculated as the number of days wages this worker would need to purchase standard treatments (as recommended in the National Standard Treatment Guidelines, 6 th edition, 2010) for selected common conditions. Page v

10 Key results Availability of medicines in the public and private sector Mean availability of originator brand and generic medicines in the public sector was 2.7% and 19.3 %, respectively. However, the mean availability of originator brand and generic medicines was 9.0% and 17.4% for the private sector and 4.6% and 21.7% for the mission sector, respectively. Public sector procurement prices In the public sector, the central medical store (CMS) is purchasing medicines at prices 1.43 times (at a MPR of 1.43) higher than international reference prices, indicating a reasonable level of purchasing efficiency. Public sector patient prices Final patient prices for generic medicines in the public sector are about three times higher than their international reference prices. Public sector patient prices for generic medicines are % higher than those bought at central procurement, indicating the extent of mark ups in the public sector distribution chain. Private sector patient prices Final patient prices for originator brands and lowest priced generics in the private sector are about and 3.37 times their international reference prices, respectively. Affordability of standard treatment regimens In treating common conditions using a standard regimen, the lowest paid government worker would need between 0.2 (diarrhoea), 0.6 (moderate pneumonia), and 1.3 (malaria) days wages to purchase lowest priced generic medicines from the private sector. Conclusions The results of the survey show that child specific medicines are not readily available in Ghana. Page vi

11 Recommendations Based on the above results, the following recommendations can be made for improving the availability, price and affordability of medicines in Ghana: In response to the low availability of child specific medicines in the health system, there is a need to strengthen the national medicines selection process to include essential medicines in the right formulations and strengths for children (i.e. childspecific medicines). These medicines will then be included in the national essential medicines list (EML) and national health insurance scheme (NHIS) reimbursement list to ensure subsequent procurement, distribution and reimbursement. The private sector (local manufacturers) should be supported and actively engaged to meet the demand for child specific medicines in Ghana. Private wholesalers and distributors should also be engaged to procure child specific medicines as part of their product lines. Thus the private sector supply chain can augment efforts in the public supply system. Prescribers and dispensers should be informed about available child specific formulations to ensure appropriate prescription and dispensing. There is an existing opportunity within the Drugs and Therapeutics Committee (DTC) framework to support such action. Page vii

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13 INTRODUCTION The Better Medicines for Children (BMC) project was initiated by the World Health Organization in 2009 with funding from the Bill and Melinda Gates Foundation. The overarching goal of the project is to improve access to essential medicines for children in priority countries by addressing availability, safety, efficacy and price. The objectives of the project include: promoting access to essential medicines for children, advocating for their inclusion in national essential medicines lists, treatment guidelines and procurement schemes; working with drug regulatory authorities to expedite regulatory assessment of essential medicines for children; developing measures to monitor and manage their prices. Ghana embraced the BMC project in support of country efforts geared towards reducing child mortality in line with the Millennium Development Goals (Goals 4 and 6), (UNDP, 2008). Equitable access to essential medicines for children and their rational use are necessary for achievement of national and global child mortality targets. Infant and under five mortality rates in Ghana are estimated at 50 and 80 deaths respectively per 1000 births (Ghana Statistical Service (GSS); Ghana Health Service and ICF Macro, 2009). Estimates from 2001 to 2006 show that Ghana s under five mortality rate remains high, at 111 per 1000 live births, (UNICEF, 2006). Declines in child mortality that began in the 1980s have slowed. Between 1984 and 1998, child mortality declined by 43/1000 live births. Between 1999 and 2006, child mortality remained static. Newborn deaths between birth and 28 days of life are now an important component of child mortality, representing 40% of all deaths (43/1000 live births in 2003) (Ghana Statistical Service (GSS); Noguchi Memorial Institute of Medical Research (NMIMR); and ORC Macro, 2004). Mortality varies between geographic areas and is influenced by a number of factors including the age and level of education of the mother, birth interval, rural or urban residence and household income. Most deaths are preventable by access to safe, essential, child specific medicines with the necessary framework for their rational use. Thus, the BMC project seeks to increase access to child specific medicines within the framework of existing policy. From August to October 2010, the Ghana National Drugs Programme conducted a nationwide study to document prices, availability and affordability of a selection of childspecific medicines in Ghana. Page 1

14 This study was conducted using an adaptation of the standardized methodology developed by the World Health Organization (WHO) and Health Action International (HAI). The WHO/HAI methodology is described in the manual Measuring Medicine Prices, Availability, Affordability and Price Components (WHO/HAI, 2008), which is accessible on the HAI website (World Health Organization and Health Action International, 2008). OBJECTIVES The main objectives of the study are to: determine the availability of originator brand and generic versions of child specific medicines in the public and private sectors; assess the efficiency of purchasing child specific medicines in the public sector compared with international reference prices; determine the price of originator brand and generic medicines in the public and private sectors, and compare them to international reference prices; determine the difference in price of originator brand products and their generic equivalents; assess the affordability of treating common childhood illnesses. COUNTRY BACKGROUND Ghana is a relatively small country, covering an area of km 2, which is divided into 10 administrative regions. The population is 23.5 million (World Bank, 2009) with the majority of Ghanaians living in rural areas (56.2%) (Ghana Statistical Service, 2009). Ghana is a low income country with a Gross Domestic Product of US$ 647 per capita. About 30% of the population lives on less than US$1 per day, with 53.6% living on less than US$ 2 per day. Of the total labour force, approximately 11.2% is unemployed. Health sector In 2006, total per capita expenditure on health was US$ 33 (average exchange rate). Approximately 5.1% of Ghana s GDP is spent on health. The government s total expenditure on health is 34.2%, which represents 4.4% of all government expenditure. The remaining 65.8% of expenditure on health is private, of which 77.8% is out of pocket expenditure through the national health insurance scheme (World Health Statistics, 2009). The public health sector is composed of the following levels: tertiary/teaching hospitals; regional hospitals; psychiatric/specialist hospitals; district hospitals; polyclinics; primary health care centres/clinics; maternity homes; and community based health planning and services (CHPS) compounds. The services offered at each level depend on the facility s capacity to manage diseases and all related medicines effectively at that level. Thus, the national medicines selection process incorporates levels of care controls with integrated triggers for referrals to higher levels of care. Page 2

15 Approximately 55% of the population has health coverage through the national health insurance scheme. The public health sector is complemented by the private sector, comprising private medical and dental practitioners, private hospitals and clinics, and mission based health facilities; these represent approximately 45% of total health services. Pharmaceutical sector There are approximately 8000 licensed, private retail medicine outlets in Ghana. A substantial proportion of medicines is dispensed to patients by the public sector and the private sector, including mission and private medical and dental practitioners. National Medicines Policy Ghana has an official National Medicines Policy (NMP) document. The 2004 National Medicines Policy provides a framework for coordinating activities in the sector involving public entities, private nongovernmental organizations (NGOs), donors, and other stakeholders by specifying the goals and strategies for attaining them. The policy, however, does not have an implementation plan or processes to achieve these strategies. There is a need to review the existing document and make it implementable. Regulatory system Ghana has a medicines regulatory authority the Food and Drugs Board (FDB) which is funded by the government and fees from the registration of medicines. Legal provisions underpinning the board require transparency and accountability and promote a code of conduct for its regulatory work. The FDB provides information on legislation, regulatory procedures, prescribing information (such as indications, contraindications, side effects, etc.), authorized companies and approved medicines. Registration fees differ for originator brands and generic equivalents, and for imported and locally produced medicines. Ghana has a quality management system with a defined protocol for ensuring the quality of medicines. Medicine samples are tested for the purposes of medicines registration and postmarketing surveillance. Regulatory procedures are in place for ensuring the quality of imported medicines. There is, however, a need to strengthen the existing structures for the sake of efficiency. Legal provisions are in place for licensing prescribers and pharmacies. Prescribing by generic name is obligatory in public sectors. The medicines policy allows for generic substitution. As a result, there is no incentive to dispense generic medicines. There are provisions in the medicines legislation and regulations covering promotion and advertising of medicines. Page 3

16 Medicines supply system Public sector medicines procurement and distribution is the responsibility of the Ministry of Health. Public sector procurement is pooled at the national level, but centralized at regional level. The following tender processes are used for public sector procurement: international competitive bidding; national competitive bidding; and negotiation/direct purchasing (including national shopping, sole sourcing and others). These are stated as percentage of total cost. National competitive tender 21% International competitive tender 37% National shopping 28% Sole sourcing 11% CMS/RMS/Others 3% Total 100% (Ghana Ministry of Health Procurement Unit, 2006) Public sector procurement is limited to medicines on the Essential Medicines List (EML). Medicines financing In 2007, total public expenditure for medicines was more than US$ 40.3 million. Ghana has a policy of providing some medicines free of charge at primary care facilities in the public sector to patients who cannot afford them, children, pregnant women and elderly people. The following are true for Ghana with respect to medicines pricing: Registration and consultation fees are commonly charged at primary care facilities. Revenues from fees or the sale of medicines are never used to pay the salaries or supplement the income of public health personnel in the same facility. In Ghana, more than 50% of the population have public health insurance, which covers selected essential medicines (National Health Insurance Authority, 2011). Ghana does not have a national medicine price monitoring system. There are no regulations requiring retail medicine pricing information to be made publicly accessible. Rational use of medicines Ghana updated its National Essential Medicines List (NEML) in A committee is responsible for the selection of medicines for the NEML, which is used for public sector procurement. The Ministry of Health, through the Ghana National Drugs Programme (GNDP), produces national Standard Treatment Guidelines (STG) for major conditions. These were updated in Page 4

17 Drug donations There are official guidelines on medicine donations that provide regulations for donors and provide guidance to the public, private, and/or NGO sectors on accepting and handling donated medicines. METHODOLOGY Overview A survey of prices, availability and affordability of child specific medicines in Ghana was conducted using an adaptation of the standardized WHO/HAI methodology (World Health Organization and Health Action International, 2008). Data on the availability and final (client) prices of medicines were collected in medicine outlets in the public, private and mission sectors. Government procurement prices were also surveyed. Selection of medicine outlets Sampling was conducted in a manner consistent with the WHO/HAI methodology, which was modified in line with the BMC project methodology globally. This modified approach has been shown, through a recent validation study, to yield a nationally representative sample of medicine outlets (Madden, Meza, & Ewen, 2010). Three regions were selected as survey areas for data collection. A combination of random and purposive sampling methods was used. A major urban centre and two non urban areas were selected. This resulted in the following three survey areas, which geographically represent the southern, middle, and upper belts of Ghana: 1. Greater Accra Region (major urban centre, purposefully selected based on its unique socio cultural and socio economic characteristics) 2. Ashanti Region 3. Upper West Region In each survey area, the sample of public sector medicine outlets was identified by first selecting the main public hospital. An additional four public medicine outlets (e.g. hospital out patient medicine outlets, dispensaries) per survey area were then selected at random from those within a four hour drive from the main hospital. In Ghana, this selection was made from all public facilities expected to stock most of the medicines in the survey, namely tertiary/secondary hospitals, district hospitals, and primary health care centres. Facilities that were not expected to stock medicines due to their levels of care were excluded from the sampling frame. The public sector sample of 15 public outlets contained five public medicine outlets in each of the three survey areas. The private sector sample was selected by identifying the private sector medicine outlet closest to each of the selected public medicine outlets, yielding a total Page 5

18 of 30 private outlets; these included five private hospitals, three private pharmacies and two licensed chemical sellers. One mission hospital per survey area was selected for the mission sector sample. In the Greater Accra Region however, an additional mission hospital was added to yield adequate data for analysis. Table 1. Sample of public, private and mission sector medicine outlets Public sector Private sector Mission sector Total number of medicine outlets per survey area Survey Area 1 (Greater Accra Region- Southern) - 1 tertiary hospital - 2 district hospitals - 2 primary care centres - 5 private hospital pharmacies - 3 pharmacies - 2 licensed drug stores Survey Area 2 (Ashanti Region Middle) - 1 tertiary hospital - 2 district hospitals - 2 primary care centres - 5 private hospital pharmacies - 3 pharmacies - 2 licensed drug stores - 1 mission hospital pharmacy Survey Area 3 (Upper West Region Upper) - 1 tertiary hospital - 2 district hospitals - 2 primary care centres - 5 private hospital pharmacies - 3 pharmacies - 2 licensed drug stores - 2 mission hospital - 1 mission hospital pharmacy pharmacy Grand total = 49 outlets Selection of medicines to be surveyed A total of 30 (representing 38 formulations) medicines were surveyed 31 formulations from the WHO BMC core list and seven supplementary medicines selected at the country level. For each medicine in the survey, up to two products were monitored, namely: originator brand (OB) the original patented pharmaceutical product; lowest priced generic equivalent (LPG) the lowest priced in the facility at the time of the survey. The methodology also includes the dosage form and strength that is to be collected for each medicine. This ensures that data on comparable products are collected across facilities. The full list of survey medicines is provided in Annex 1. Data collection The survey team consisted of a survey manager, three area supervisors, 12 data collectors, and two data entry personnel. All personnel received training in the standard survey methodology, and data collection and data entry procedures at a workshop held from August As part of the workshop, a data collection pilot test was conducted at public and private medicine outlets, which did not form part of the survey sample. Data collection took place over 13 days from 6 18 September Data collectors visited medicine outlets in pairs and collected information on medicine availability and pricing Page 6

19 using a standard data collection form specific to the medicines being surveyed in Ghana (see Annex 2). Area supervisors checked all forms at the end of each day, and validated the data collection process by collecting data at 20% of the medicine outlets and comparing their results with those of the data collectors. Upon completion of the survey, the survey manager conducted a quality control check of all data collection forms prior to data entry. Public procurement data was collected on the prices that the government pays to procure medicines. Data was collected for the same medicines as surveyed in medicine outlets. Procurement data was obtained from recent procurement orders from Central Medical Stores (CMSs). Data entry Survey data was entered into a pre programmed Microsoft Excel Workbook provided as part of the WHO/HAI methodology. Data entry was checked using the ʹdouble entryʹ and ʹdata checkerʹ functions of the Workbook. Erroneous entries and potential outliers were corrected as necessary. Data analysis The availability of individual medicines is calculated as the percentage of medicine outlets where the medicine was found. Mean (average) availability is also reported for the overall list of surveyed medicines. The availability data only refers to the day of data collection at each particular facility and may not reflect average monthly or yearly availability of medicines at individual facilities. Medicine prices obtained during the survey are expressed as ratios relative to a standard set of international reference prices: Medicine Price Ratio (MPR) = median local unit price international reference unit price The ratio is thus an expression of how much more or less the local medicine price is than the international reference price; e.g. an MPR of 2 would mean that the local medicine price is twice that of the international reference price. MPRs were only calculated for medicines with price data from at least four medicine outlets, unless otherwise indicated. For procurement prices, a single data point was accepted. All prices were converted to US dollars using the exchange rate (buying rate) posted on 13 September 2010, the first day of data collection, i.e. US$ 1 = 1.43 GHC (Bank of Ghana, 2010). The reference prices used in this survey were the 2009 Management Sciences for Health (MSH) reference prices, taken from the International Drug Price Indicator Guide. They represent actual procurement prices for medicines offered to low and middle income countries by non profit suppliers and international tender prices. These agencies typically sell in bulk quantity to governments or large NGOs. They have relatively low procurement prices that represent efficient bulk procurement without the costs of shipping or insurance. Page 7

20 Price results are presented for individual medicines, as well as for the overall list of 38 medicines surveyed. Summary results for the list of medicines have been shown to provide a reasonable representation of medicines in the country and price conditions on the market. As averages can be skewed by outlying values, median values have been used in the price analysis as a better representation of the midpoint value. The magnitude of price and availability variations is presented as the interquartile range. A quartile is a percentile rank that divides a distribution into four equal parts. The range of values containing the central half of the observations, that is, the range between the 25 th and 75 th percentiles, is the interquartile range. Finally, the affordability of treating four common childhood conditions pneumonia, diarrhoea, worm infestation, and malaria was assessed by comparing the total cost of medicines prescribed at a standard dose, to the daily wage of the lowest paid unskilled government worker (3.11 GHC/day and US$ 2.17 at the time of the survey). Although it is difficult to assess true affordability, treatments costing one day s wage or less (for a full course of treatment for an acute condition, or a 30 day supply of medicine for chronic diseases) are generally considered affordable. RESULTS 1. AVAILABILITY OF MEDICINES ON THE DAY OF DATA COLLECTION Figure 1: Mean percentage availability of child-specific medicines on the day of data collection; public, private, and mission sectors Page 8

21 Results show: Average availability of all survey medicines in the public sector was low at 2.7 % for originator brand products and 19.3% for generics (see Figure 1). When analysis is limited to survey medicines listed on the NEML, public sector availability increases to 3.8% and 28.6% for originator brand products and generics, respectively. Average availability in the private sector was low at 9.0% and 17.4% for branded and generic products, respectively. Average availability in the mission sector was also low at 4.6% and 21.7% for originator brand and lowest price generic products, respectively. This was slightly higher than the public sector, which recorded 2.7% and 19.3% for originator brand products and lowest price generics, respectively Across sectors, the private sector had the highest relative availability of originator brand products. In all sectors, generics were the predominant product type available. When availability is analysed by therapeutic class (see Table 2), it can be seen that oralrehydration salts were available in 75% or more of the facilities in each of the public, private, and mission sectors. However, zinc dispersible tablets were not found in any of the facilities surveyed. Antibiotics had variable availability depending on the medicine and sector surveyed. Amoxicillin suspension was the most frequently available antibiotic, with 100% availability in both the public and private sectors. Conversely, amoxicillin dispersible tablet, cotrimoxazole dispersible tablet, and gentamicin injection were not available in any of the facilities surveyed. For antimalarials, quinine injection had reasonable availability in public (80%) and mission (100%) facilities, while artemether lumefantrine dispersible tablet had low availability (<10%) in these sectors, but higher availability in the private sector (46.7%). Artesunate/amodiaquine dispersible tablet had low availability (<10%) in all three sectors. For anti asthmatics, salbutamol was available in about one third, one quarter, and half of facilities in the public, private, and mission sectors, respectively, while beclometasone was not found at all. Page 9

22 Table 2: Availability of individual generic medicines by therapeutic class Therapeutic group Medicine name Public sector (n-15) % Private sector (n-30) % Mission sector (n-4) % Antianaemia Ferrous salt, suspension Antiasmetics Beclomelasone, inhaler Antiasmetics Salbutamol, inhaler Antibiotics Amoxicillin, dispersible tablet Antibiotics Amoxicillin/clavulanic acid, suspension Antibiotics Cotrimaxazole, dispersible tablet Antibiotics Gentamycin, injection Antibiotics Procaine penicillin, injection Antibiotics Amoxicillin clavulanic acid, suspension Antibiotics Amoxicillin/clavulanic acid, dispersible tablet Antibiotics Ceftriazone, injection Antibiotics Azithromycin, powder Antibiotics Chloramphenicol, injection Antibiotics Benzylpenicillin, injection Antibiotics Amoxicillin, suspension Antiepileptic Carbamazepine, chewable tablet Antiepileptic Carbamazepine, suspension Antiepileptic Diazepam, rectal solution Antiepileptic Phenytoin, chewable Antiepileptic Phenytoin, suspension Antiepileptic Phenobarbital, oral liquid Antiepileptic Carbarmazepine, tablet Antiepileptic Phenobarbital, injection Antimalarial Artesunate/amodiaquine, dispersible tablet Antimalarial Artemether+lumefantrine, dispersible tablet Antimalarial Quinine, injection Antituberculosis Isoniazid, scored tablet Intestinal Mebendazole, tablet anthelminthics Medicines used in Zinc, dispersible tablet diarrhoea Medicines used in Oral rehydration solution (ORS), diarrhoea sachet Medicines used in Oral rehydration solution (ORS), diarrhoea sachet NSAIDS Paracetamol, suspension NSAIDS Ibuprofen, tablet Opiods analgelsics Morphine, immediate release tablet Opiods analgelsics Morphine, oral solution Vitamins Vitamin A, capsules Vitamins Vitamin K1, injection-water soluble Page 10

23 Annex 3 contains the availability of individual medicines in the public, private and mission sectors. In the public sector, medicines that were not found at any facilities (0% availability) were: amoxicillin dispersible tablet, amoxicillin/clavulanic, acid suspension, artesunate/ amodiaquine dispersible tablet, beclometasone inhaler, carbamazepine chewable tablet, carbamazepine suspension, cotrimoxazole dispersible tablet, diazepam rectal solution, gentamycin injection, isoniazid scored tablet, morphine immediate release tablet, phenytoin chewable, phenytoin suspension, ferrous salt suspension, paracetamol suspension, procaine penicillin injection, vitamin A capsules, and zinc dispersible tablet. Medicines that were not found at any facilities in the private or mission sectors were: amoxicillin dispersible tablet, amoxicillin/clavulanic acid suspension, beclometasone inhaler, cotrimoxazole dispersible tablet, diazepam rectal solution, gentamycin injection, carbamazepine suspension and chewable tablet, phenytoin suspension and chewable tablet, morphine oral solution, phenobarbital oral liquid and zinc dispersible tablet. 2. PUBLIC SECTOR PRICES 2.1 Public sector procurement prices Table 3. Public sector procurement: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Product type Median MPR 25 th percentile 75 th percentile Originator brand (n = 0 medicines) Lowest-price generic (n = 8 medicines) Of the 38 medicines included in the survey, no originator brands and eight generics were found in the public procurement sector. Based on the median MPRs, the public sector is procuring generics at 1.43 times their international reference prices. Thus, the government procurement agency is purchasing with moderate efficiency. The interquartile range shows moderate variation in MPRs across individual medicines. Further investigation is required to identify the determinants of these variations in purchasing efficiency. Annex 4 contains procurement prices for individual medicines. Generic medicines being purchased at prices significantly less than international prices include benzylpenicillin injection (MPR = 0.46) and carbamazepine tablets (MPR = 0.49). Conversely, medicines for which the government is paying several times the international reference price include mebendazole tablets (MPR = 2.51), oral rehydration solution (ORS) sachet (MPR = 3.33), and phenobarbital injection (MPR = 2.64). Page 11

24 2.2 Public sector patient prices Table 4. Public sector patient prices: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Product type Median MPR 25 th percentile 75 th percentile Originator brand (n = 1 medicine)* Lowest-price generic (n = 11 medicines) The results above show that in the public sector: One originator brand medicine (artemether lumefantrine dispersible tablet) was found with sufficient price data to enable calculation of the MPR. This medicine was being sold at an estimated 2.06 times its international reference price. Lowest price generic medicines are generally sold at 3.35 times their international reference price. Half of the lowest price generic medicines were priced at 2.30 (25 th percentile) to 4.19 (75 th percentile) times their international reference price. There is therefore moderate variation in MPRs across individual generic medicines. Annex 5 contains the MPRs for individual medicines found in the public sector for which one or more price points were found. Originator brand medicines priced several times higher than international reference prices include mebendazole tablet (MPR = ), ceftriaxone injection (MPR = 17.50), azithromycin powder (MPR = 9.99) and salbutamol inhaler (MPR = 4.42). The 25 th and 75 th percentiles for individual medicines show that for originator brands, prices vary significantly between public sector medicine outlets. Lowest price generic medicines priced several times higher than international reference prices include mebendazole tablet (MPR = 52.45), carbamazepine tablet (MPR = 10.23), ceftriaxone injection (MPR = 5.02), and ORS sachet (MPR = 4.28). The 25 th and 75 th percentiles for individual medicines show that for generic medicines, prices vary significantly between public sector medicine outlets. 2.3 Comparison of patient prices and procurement prices in the public sector Table 5. Median MPRs for medicines found in both public procurement and public sector medicine outlets (final patient prices) Product type Lowest-price generic (n = 8 medicines) Median MPR Public Procurement Median MPR Public Patient Prices % difference patient prices to procurement % Only those medicines found in both public procurement and public sector medicine outlets were included in the analysis for Table 5 to allow for the comparison of purchase price to final patient price. Results show that final patient prices in the public sector are 101.9% higher than procurement prices for generic equivalents. These price differences may result Page 12

25 from local purchases at public health facilities and/or from add on costs applied in the distribution chain. 3. PRIVATE SECTOR PATIENT PRICES Table 6. Ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Product type Median MPR 25 th percentile 75 th percentile Originator brand (n = 8 medicines) Lowest-price generic (n = 14 medicines) Table 6 shows that in the private sector: Originator brand medicines are generally sold at times their international reference price. Half of the originator brand medicines were priced at 3.68 (25 th percentile) to (75 th percentile) times their international reference price; there is therefore substantial variation in MPRs across individual originator brand medicines. Lowest price generic medicines are generally sold at 3.37 times their international reference price. Half of the lowest priced generic medicines were priced at 2.28 (25 th percentile) to 4.59 (75 th percentile) times their international reference price. There is therefore moderate variation in MPRs across individual generic medicines. Annex 6 contains the median price ratios for individual medicines found in the private sector for which one or more price points were found. Originator brand medicines priced several times higher than international reference prices include mebendazole tablet (MPR = ), ceftriaxone injection (MPR=28.09), azithromycin powder (MPR=16.97), carbamazepine tablet (MPR = 12.79), and amoxicillin suspension (MPR = 9.32). The 25 th and 75 th percentiles for individual medicines show that, for originator brands, prices vary significantly between private sector medicines outlets. Lowest price generic medicines priced several times higher than international reference prices include mebendazole tablet (MPR = 21.85), morphine immediate release tablet (MPR=9.11), phenobarbital injection (MPR = 7.65), vitamin A capsules (MPR = 7.36), procaine penicillin injection (MPR = 6.48) and ceftriaxone injection (MPR = 5.64). The 25 th and 75 th percentiles for individual medicines show that, for generic medicines, prices vary significantly between private sector medicines outlets. Figure 2 suggests that the price for a ceftriaxone injection is 28.1, 5.6 times the international reference price; while the price for artemether+lumefantrine dispersible tablet is 2.1 and 1.2 times the international reference price for originator branded and lowest price generics, respectively. The difference in MPR for originator brand and lowest price generics across the five selected medicines in Figure 2 is noteworthy. Whiles the originator brand lowest price generic MPR difference is relatively small, that for azithromycin and ceftriaxone is huge. This phenomenon can be due to the impact of medicines affordability initiatives e.g. Affordable Medicines for Malaria Initiative, or it may need further investigation. Page 13

26 Figure 2: Median price ratios for selected child-specific medicines, originator brand and lowest-price generic equivalents, private sector 4. MISSION SECTOR PATIENT PRICES Table 7. Ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found Product type Median MPR 25 th percentile 75 th percentile Originator brand (n = 3 medicines) Lowest price generic (n = 14 medicines) Table 7 shows that in the mission sector: Lowest price generic medicines are generally sold at 3.39 times their international reference price. Half of the lowest priced generic medicines were priced at 3.04 (25 th percentile) to 3.75 (75 th percentile) times their international reference price. There is therefore only a small variation in MPRs across individual generic medicines. 5. COMPARISON OF PATIENT PRICES IN THE PUBLIC AND PRIVATE SECTORS Table 8. Median MPRs for medicines found in both public and private sectors Product type Median MPR Public sector patient prices Median MPR Private sector patient prices % difference private to public Originator brand (n = 5 medicines) % Lowest-price generic (n = 16 medicines) % *To enable comparison of a greater number of products, medicines with a minimum of one price point were included in the analysis, compared to the four price points usually required. Page 14

27 Only those medicines found in both public and private sector medicine outlets were included in the analysis (Table 8) to allow for comparison of prices between the two sectors. Results show that final patient prices in the private sector are 69.8% and 37.0% higher than in the public sector for originator brands and generic equivalents, respectively. Given that overall availability of medicines in the public sector is low, patients are paying substantially higher prices to purchase medicines from the private sector. 6. AFFORDABILITY OF STANDARD TREATMENT REGIMENS The affordability of treatment for four common conditions was estimated as the number of daysʹ wages of the lowest paid, unskilled government worker needed to purchase medicines prescribed at a standard dose. For all the conditions, treatment duration was defined as a full course of therapy as specified in the Ghana Standard Treatment Guidelines 6 th Edition (2010). The daily wage of the lowest paid unskilled government worker used in the analysis was 3.11 GHC. Condition Pneumonia Table 9. Number of days' wages of the lowest-paid government worker needed to purchase standard treatments from the private sector Drug name, strength, dosage form *** Amoxicillin 125 mg/5 ml Age Group Child 1-5 years Diarrhoea ORS sachet Child 2-10 years Worm infestation Malaria Malaria Mebendazole 500 mg Artesunate +amodiaquine, dispersible tablet 25 mg+ 75 mg Artemether +lumefantrine dispersible tablet 20 mg +120 mg Child > 12 months Child 1-6 years Child 3-8 years STG ** First-line treatment: Amoxicillin oral 250 mg 8 hourly for 7 days First-line: ORS 500 ml or more as necessary First-line : Mebendazole 500 mg as single dose Treatment of choice: AA Day 1: 2 tablets (50 mg+150 mg) Day 2: 2 tablets (50 mg+150 mg) Day 3:2 tablets (50 mg+150 mg) Alternative treatment: Day 1: 2+2 tablets Day 2: 2+2 tablets Day 3: 2+2 tablets Total # of Units per Treatment 2 bottles (200 ml) * Less than four data points have been used to compute this aggregate value. ** (Ministry of Health, Ghana National Drugs Programme, 2010) *** (Ministry of Health, Ghana National Drugs Programme, 2010) Median price for Lowestpriced generic product in the private Sector (GHS) 2 sachets /sachet 1 tablet /tablet 6 tablets * /tablet 12 tablets * /tablet Median Treatme nt Price (GHS) Based on lowest price generic products /ml days days days days days Page 15

28 Figure 3: Number of days wages required to treat selected uncomplicated conditions based on standard treatments The affordability of lowest price generics in the public sector was reasonable for the conditions in Figure 3, with standard treatment costing less than, or just over, a day s wage. However, given the low availability of medicines in the public sector, many patients are forced to purchase medicines from the private sector; therefore the high number of days wages required is of concern, especially for the treatment of malaria in children. It should be noted that treatment costs refer to medicines only and do not include the additional costs of consultation and diagnostic tests. Further, many people in Ghana earn less than the lowest government wage. As such, even treatments that appear affordable are too costly for the poorest segments of the population. Finally, even where individual treatments appear affordable, individuals or families who need multiple medications may quickly face unmanageable costs. Discussion The results indicate that in the public sector, the procurement of child specific medicines is moderately efficient, as shown by purchase prices reasonably higher than international reference prices. As a result of add on costs in the public sector distribution chain, by the time these medicines are sold to patients prices have increased by 101.9%. Based on the tracer medicines list, the public sector is purchasing only generic products, which is in line with the national drug policy. Availability of generic child medicines in the public sector is poor. The average availability was around 20% in all sectors, while in the public sector the availability of medicines on the Page 16