(Read this to the study participant) Price Data Collection Form Use a separate form for each medicine outlet "Boston University in collaboration with and IPA is conducting a study on the availability and price of medicines for four chronic diseases (Asthma, breast cancer, diabetes, and cardiovascular diseases (hytension, dyslipidemia and Heart failure) in Kenya. We would like ask you a few questions on the availability and price of these medicines in your facility. We would be grateful if you could respond as honestly as possible to these questions. Thank you so much for giving us this opportunity to speak with you Section A: Facility information Date : County ID: EA ID Name of town/village: Name of medicine outlet : outlet unique survey ID (mandatory): Distance in km from nearest town (population >50 000): Type of medicine outlet : Public sector facility (hospital/clinic - specify level of care below): Level 5 facility Level 4 facility Level 3 facility Level 2 facility Private non-profit health facility (hospital/clinic - specify the level of care below) Level 5 facility Level 4 facility Level 3 facility Level 2 facility Pharmacy/Chemist Type of data: Sample outlet (not to be collected at baseline) validation visit Name of manager of the medicine outlet: Tel. No.1: Tel. No.2: Name of son(s) who provided information on medicine prices and availability (if different from manager):. Tel. No.1 Tel. No. 2 Name of data collectors:
Section B: s availability and price Lowest priced generic equivalent product: determined at facility Generic name, dosage form, strength Amitriptyline 25mg 25mg Amlodipine 10mg 10mg Amlodipine 5mg 5mg Amoxicillin 250mg 250mg dissible Amoxicillin 500mg 500mg Anastrozole 1mg 1mg film-coated Atenolol 50mg 50mg Bisoprolol 10mg 10mg film-coated Bisoprolol 2.5mg 2.5mg film-coated Bisoprolol 5mg 5mg film-coated Type Available yes/no Brand or product name(s) Manufacture r Pack size recommended Pack size found Price of pack found - (patien t price) Unit patient price (4 decimal places) 100 90 Sandoz 90 generic 90 30 Sandoz 30 20 dissible dissible Sandoz 20 dissible generic 20 21 generic 21 30 Sandoz 30 60 100 Sandoz 100 30 Sandoz 30 100 Sandoz 100 Comments No No No No No
Captopril 25mg 25mg Ceftriaxone 1g/vial 1 g/vial Injection Ciprofloxacin 500mg 500mg Co-trimoxazole (sulfamethoxazole+ trimethoprim) 8+40mg/ml 8+40mg/ml Diazepam 5mg 5mg Diclofenac 50mg 50mg Furosemide 40mg 40mg Glibenclamide 5mg 5mg Glimeide 1mg 1mg Glimeide 2mg 2mg Glimeide 4mg 4mg Hydrochlorothiazide 25mg 25mg 60 1 Injection generic 1 Injection 10 generic 10 100 100 100 50 Sandoz 50 generic 50 60 30 Sandoz 30 90 Sandoz 90 generic 90 90 Sandoz 90 generic 90 30 Sandoz 30 No No No No No
Letrozole 2.5mg 2.5mg film-coated Metformin 1000mg 1000mg film-coated Metformin 500mg 500mg film-coated Omeprazole 20mg 20 mg Paracetamol 24mg/ml 24 mg/ml Suspension Ramipril 10mg 10mg Ramipril 5mg 5mg Salbutamol 100MCG/DOS 100MCG/DOS Simvastatin 20mg 20mg film-coated Simvastatin 40mg 40mg film-coated 30 30 60 Sandoz 60 60 Sandoz 60 Sandoz 1 30 60 Suspension Suspension 100 Sandoz 100 20 Sandoz 20 generic 20 1 generic 1 30 Sandoz 30 100 100 No No No No No
Tamoxifen 20mg 20mg Valsartan 160mg 160mg film-coated Valsartan 80mg 80mg film-coated 30 Sandoz 30 28 28 generic 28 28 28 generic 28 No No 56 No Vildagliptin 50mg 50mg 56 generic 56 What is the name of the pharmacy or drug store nearest to the hospital/clinic where patients normally get their medicines?.. Also ask for the location of this pharmacy: Before leaving the facility: Data collectors should check that the data collected are accurate and complete before leaving the facility. They should report any problems as soon as possible.