THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE

THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE Assessment of the prices and availability of medicines for children in Tanzania NOVEMBER 2010

Published by the Ministry of Health and Social Welfare, Dar es Salaam, The United Republic of Tanzania. 2011 Ministry of Health and Social Welfare, The United Republic of Tanzania Any part of this document may be reproduced in any form without the prior permission of the publisher provided that this is not for profit and that due acknowledgement is given. Any reproduction for profit must be made with the prior permission of the publisher. Copies of this report may be obtained from: The Permanent Secretary Ministry of Health and Social Welfare P.O. Box 9083 Dar es Salaam Tel: 255 22 2120261 Fax: 255 22 2139951

TABLE OF CONTENTS ACKNOWLEDGMENTS... I EXECUTIVE SUMMARY...II 1. INTRODUCTION...1 1.1 Background... 1 1.2 Country background... 2 1.3 The rational use of paediatric medicines... 3 1.4 Cost sharing in Tanzania... 4 1.5 Medicine procurement... 4 1.6 Medicine prices... 5 2. OBJECTIVES...6 2.1 Broad objective... 6 2.2 Specific objectives... 6 3. METHODOLOGY...7 3.1 Description of the study areas... 7 3.2 Study population and sampling... 8 3.2.1 National level... 8 3.2.2 Selection of health facilities... 8 3.3 Survey medicines... 8 3.4 Selection and training of survey personnel... 9 3.5 Methods of data collection... 9 3.5.1 Data collection at the national level... 9 3.5.2 Data collection at health facilities... 9 3.6 Data entry and analysis... 10 3.7 Ethical considerations... 10 3.8 Expected results... 10

4. RESULTS...11 4.1 Availability of medicines in the public, private and nongovernmental organization sectors... 12 4.2 Cross sector comparison of medicine availability... 14 4.2 Facility prices in the public, private and nongovernmental organization sectors... 16 4.5 Cross sector comparison of patient prices... 19 4.6 Affordability... 22 5. DISCUSSION...23 5.1 Public sector availability... 23 5.2 Public sector prices... 25 5.3 Private sector availability and patient prices... 26 5.4 Nongovernmental Organization sector patient prices and availability... 26 5.5 Intersectoral comparison of patient prices... 27 5.6 Affordability to patients... 27 6. CONCLUSIONS...28 7. RECOMMENDATIONS...30 REFERENCES...31 BIBILIOGRAPHY...32 ANNEXES...33 Annex 1: Timetable of survey... 33 Annex 2: Medicines data collection form used for survey... 34 INSTRUCTIONS...35 Annex 3: List of facilities and outlets sampled... 42 Annex 4: List of the paediatric medicines surveyed... 44 Annex 5: Analysis summary sheets... 45

List of figures Figure 1 A map of Tanzania showing the six regions surveyed in the study: A Dar es Salaam, B Mtwara, C Mbeya, D Manyara, E Shinyanga and F Tabora... 7 Figure 2: Percentage availability of 50 target medicines in the three sectors... 14 Figure 3 price ratios of lowest price generic medicines in the private sector... 17 Figure 4: Comparison of median price ratios between public procurement prices and public sector facility (patient) prices... 20 List of tables Table 1: Trends in early childhood mortality rates... 1 Table 2: Geographical distribution of the surveyed health facilities (n = 143)... 8 Table 3: Analysis of medicine availability (%) by therapeutic class... 15 Table 4: Number of times more expensive, highest priced vs. lowest priced generics... 18 Table 5: Price variation across nongovernmental organization medicine outlets... 19 Table 6: Price difference between medicines found in both public and private sectors... 21 Table 7: Table 8: Table 9: Medicines with median price ratios > 2 in the private sector and their corresponding availability in the public sector... 21 Affordability of treating acute conditions: number of days wages the lowest paid government worker would need to spend to purchase lowest priced generic medicines in the three sectors surveyed... 22 Affordability of treating chronic conditions: number of days wages the lowest paid government worker would need to spend to purchase the lowest priced generic medicines in the three sectors surveyed... 23

ABBREVIATIONS ADDO AIDS HIV HPG LPG MDG MPR NEMLIT SD TShs Accredited drug dispensing outlets Acquired Immuno Deficiency Syndrome Human Immunodeficiency Virus Highest Price Generic Lowest Price Generic Millennium Development Goals Price Ratios National Essential Medicines List for Tanzania Standard deviation Tanzanian shillings

ACKNOWLEDGMENTS The Ministry of Health and Social Welfare would like to express its gratitude to the World Health Organization whose financial support through the Better Medicines for Children project made it possible to conduct this survey. The Ministry would also like to acknowledge all people who contributed their time and expertise throughout the survey process to make it successful. In particular we would like to mention the following: Dr Margret E. Mhando, Director for Hospital Services; Mr Joseph Muhume, Assistant Director Pharmaceutical Services; Ms Rose Shija, National Professional Officer for Essential Drugs and Medicines Policy; and Ms Alexandra Cameron, Technical Officer, Department of Essential Medicines and Pharmaceutical Policy, World Health Organization Headquarters. The Ministry is grateful to all health workers in the surveyed facilities and pharmacies for facilitating the data collection process. Similarly, the trainers of the data collectors are also acknowledged, especially Ms Anita Silo. The close cooperation and guidance received from the Regional Medical Officers and Regional Pharmacists of the regions surveyed i.e. Dar es Salaam, Manyara, Mbeya, Mtwara, Shinyanga and Tabora is highly appreciated. The Tanzania Food and Drugs Authority and the Medical Stores Department are acknowledged for providing useful information pertaining to medicine regulation and pricing respectively. Special gratitude is extended to all other people in all sectors who in one way or another gave invaluable information requested during the survey. Last but not least, the valuable work done by the data collectors and area supervisors who devoted their time and commitment to collect data is hereby acknowledged. These include: Mr L. Francis, Mr E. Lugayaza, Mr E. Mabonesho, Mr Z. Maganga, Ms S. Mapunjo, Ms S. Mashana, Mr J. Mfutakamba, Mr N. Mhadu, Dr S. Mung ong o, Mr J. Nassoro, Mr B. Nyaulingo, and Ms R. Tumbo. Finally, the Ministry of Health and Social Welfare wishes to acknowledge the Survey Manager Prof Dr M. Justin Temu for her leadership role in this survey. Assessment of the prices and availability of medicines for children in Tanzania -- Page i

EXECUTIVE SUMMARY This report describes a field study carried out in Tanzania to measure the availability and prices of paediatric medicines using the second edition of the World Health Organization/Health Action International standardized methodology. Data on the prices and availability of 50 paediatric medicines were collected from a sample of health facilities in the public, private and nongovernmental organization sectors in Dar es Salaam, Manyara, Mbeya, Mtwara, Mwanza, Shinyanga, and Tabora regions. In total, the survey team collected data from 143 facilities. Data were also collected on government procurement prices from the Medical Stores Department. For each medicine, data were collected on the highest priced generics and lowest priced generics products found at each facility. Medicine prices are expressed as median price ratio (MPR), which are ratios relative to the Management Sciences for Health International Reference Prices for 2009. Using the salary of the lowest paid unskilled government worker, affordability was calculated as the number of daysʹ wages needed to purchase medicines for standard treatments of common conditions. The availability of paediatric medicines assessed in this survey was low in all sectors. In the public sector, the mean availability of all generic medicines in the basket was only 32.0%, while availability of medicines on the national essential medicines list was higher at 45.3%. This suggests patients seeking care in the public sector must go without medicines or purchase them elsewhere, such as in the private sector. Here, the mean availability of the basket of medicines studied was only slightly higher than in the public sector (34.4%). Among nongovernmental organizations, mean availability of the basket of medicines studied was similar to that observed in the public and private sectors (32.1%). In the private sector medicines were, on average, more available in urban areas than in rural areas, while in the public and nongovernmental organization sectors availability did not vary significantly between urban and rural areas. When availability was analysed by therapeutic areas, oral rehydration solution for the treatment of diarrhoea showed moderate availability, ranging from 57.4% in the public sector to 72.9% in the private sector. However, dispersible zinc tablets were consistently less available (29.8%, 43.8%, and 33.3% in the public and private and nongovernmental organization sectors, respectively). Antibiotics had variable availability depending on the medicine and sector surveyed. For example, benzylpenicillin injection had reasonable availability in all three sectors (87.2%, 66.7% and 87.5% in the public, private and nongovernmental organization sectors, respectively). Amoxicillin suspension had high availability in private and nongovernmental organization facilities, but was only available in 55% of the public facilities surveyed. Ceftriaxone injection had poor availability in all sectors (57.1%, 25.0% and 22.9% in the public, private and nongovernmental organization sectors, respectively), as did gentamicin injection (21.3%, 6.3% and 18.8% in the public, private and nongovernmental organization sectors, respectively). For antiasthmatics, beclometasone inhaler was not available in any public or nongovernmental facilities, and was only available in 6.3% of private facilities. While salbutamol inhaler had higher availability in all three sectors, it should be noted that it is listed on the national essential medicines list as a level D medicine (regional and referral hospitals) and as such availability in the public sector only reflects availability at this level of care. Assessment of the prices and availability of medicines for children in Tanzania -- Page ii

Opioid analgesics, namely morphine suspension and tablets, were not available in any facilities in any sector. Anticonvulsants also showed consistently low availability in all sectors. With the exception of phenobarbital injection in the public sector, the availability of the anticonvulsants surveyed was consistently less than 20% in all sectors, and was often 0%. In the public sector procurement agency, the Medical Stores Department, only 27 of the 50 medicines surveyed were in stock at the time of the survey. On average, prices were 0.80 times international reference prices, indicating a good level of purchasing efficiency. However, three medicines had median price ratios substantially higher than international reference prices: epinephrine injection (MPR=1.73), phenobarbital injection (MPR=2.38), and gentamicin injection (MPR=3.14). In the public sector health facilities, generic medicines were found to have a median MPR of 0.96, ranging from 0.17 for artemether + lumefantrine dispersible tablet to 13.41 for albendazole chewable tablet. Public sector patient prices were, on average, 19.4% higher than the public sector procurement prices. In some cases patient prices were significantly higher than procurement prices. For example, albendazole chewable tablets cost 16 times the procurement price at health facilities. In the private sector, lowest price generics had a median MPR of 2.22, however within the basket median price ratios ranged from 1.49 for a salbutamol inhaler to 14.9 for albendazole chewable tablets. One quarter of the lowest priced generic medicines in the basket had median price ratios greater than 3.66, that is, prices nearly four times higher than the international reference prices. Minimal price variation was observed across private sector facilities. The lowest priced generic medicines in the private sector were priced 154.9 % higher than in the public sector. This means that a patient buying a generic medicine in the private sector would pay 154.9% times more than if the same medicine were purchased in the public sector, if it was available. In the private sector, both highest priced and lowest priced generics were found for 10 medicines, indicating that for these products private sector outlets are stocking at least two generic equivalents. Highest priced generics had a median MPR of 5.34, and were found to be on average 96% more expensive than their corresponding lowest priced generics. Among nongovernmental organizations, the lowest priced generic medicines in the basket were found to have a median MPR of 2.41, corresponding to prices 9.8% and 154.9% more than those in the private and public sectors, respectively. The affordability data indicated that the treatment of acute cases such as pneumonia, malaria, and diarrhoea with lowest priced generics cost between 0.1 and 0.3 days wages in the private sector and between 0.1 and 0.2 days wages in the nongovernmental organization sector, while in the public sector it was free. The treatment of malaria with artemether + lumefantrine was subsidized in both public and nongovernmental organization sectors. The treatment of asthma using the lowest priced generic salbutamol inhaler cost 0.9 and 0.7 days wages in the private and nongovernmental organization sectors, respectively, while in the public sector it was free. Although these treatments appear relatively affordable it should be noted that other treatment costs such as consultation fees and diagnostic tests have not been included; total treatment costs would therefore be considerably higher. Assessment of the prices and availability of medicines for children in Tanzania -- Page iii

In conclusion, the availability of paediatric medicines assessed in this survey was low across all sectors. While the public sector dispenses most medicines for children free of charge, low availability may lead people to purchase medicines in the private sector or go without treatment. In the private and nongovernmental organization sectors some medicines cost several times their international reference price and may not be affordable for the poorest segments of the population. Therefore the availability, price and affordability of paediatric medicines in Tanzania should be improved in order to ensure equity in access to basic medical treatments, especially for the poor. Also sustained availability of medicines is crucial to assist the country in reaching the goals it has set within the National Road Map Strategic Plan to Accelerate the Reduction of Maternal, Newborn and Child Deaths in Tanzania, 2008 2015; Health Sector Strategic Plan III, 2009 2015; Mkakati wa Kukuza Uchumi na Kupunguza Umaskini Tanzania (National Strategy for Growth and Reduction of Poverty II, 2010 2014); as well as the Millennium Development Goals. Progress will require a multi faceted approach, as well as the review and refocusing of policies, regulations and educational interventions. Assessment of the prices and availability of medicines for children in Tanzania -- Page iv

1. INTRODUCTION 1.1 Background According to the World Health Organization, nearly nine million children die every year, many of them from treatable conditions such as diarrhoea, malaria, respiratory tract infections or pneumonia (1). Effective treatments exist for many of these conditions, yet are often unavailable for children. This occurs for a variety of reasons, including the lack of appropriate formulations, the lack of clinical trials in children, the need for off label use of medicines, inadequate procurement and supply systems, and the cost of medicines. In 1989, heads of state ratified the Convention on the Rights of the Child, which recognizes that every child has the right to survive. Renewed commitments to sustainable development, nutrition, and reduction of communicable diseases were made during the United Nations Special Session on Children in 2002. The increased attention to the United Nations commitment for child survival was again echoed by the Millennium Development Goals (MDGs). Specifically, MDG 4 calls for reduction of under five mortality by two thirds by the year 2015. Other related goals include MDG 1 (reduction of hunger), MDG 5 (improved maternal survival), MDG 6 (combating HIV/AIDS and malaria) and MDG 8.E (improved access to medicines). In Tanzania, despite the gains and various efforts to improve maternal, newborn, and child health service delivery, the coverage of interventions is still low. There are obvious urban rural disparities, as well as significant differences among the districts. In addition to low coverage, there is inadequate resource allocation for maternal, newborn, and child health services, poor quality of service, limited access, insufficient community participation, and weak linkages between maternal, newborn, and child health and related programmes (2). However, trends show that childhood mortality has declined considerably over the past 10 to 15 years (3). Survey Year Table 1: Trends in early childhood mortality rates Infant and under-five mortality rates, Tanzania, 1996-2010 Approximate Infant calendar period mortality rate Under-five mortality rate (per 1,000) (per 1,000) 1996 1992-1996 88 137 2004-2005 2000-2004 68 112 2007-2008 2003-2007 58 91 2010 2006-2010 51 81 Improved child survival rates, as shown in Table 1, are attributed to a combination of interventions, including gains in malaria control through improved diagnosis and treatment of malaria, as well as prevention through increased use of insecticide treated nets. In addition, the success of preventive measures such as measles vaccination, nutrition interventions, HIV/AIDS prevention and care, Expanded Programme on Immunization and implementation of the Integrated Management of Childhood Illness has greatly reduced morbidity and mortality and improved the wellbeing of children (4). Assessment of the prices and availability of medicines for children in Tanzania -- Page 1

There is a notable lack of information at the local, national and international levels about the availability and cost of key medicines used in children. Also these medicines are often not included in national essential medicines lists and standard treatment guidelines. Studies have shown that children s formulations are not available because of the competition to develop medicines for adults and the expectation that an adult formulation will be adapted for use in children. In May 2007, the World Health Assembly passed a resolution to strengthen and support activities to make medicines more readily available to children and to promote the development of evidence based treatment guidelines to ensure that drugs are used appropriately in children. Following this, the World Health Organization initiated the Better Medicines for Children project in 2009, with funding from the Bill and Melinda Gates Foundation. The goal of the project is to improve access to essential medicines for children by addressing issues of availability, safety, efficacy and price. One of the four strategic objectives of the project is to promote access to essential medicines for children in priority countries by promoting 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; and developing measures to monitor and manage their prices. Tanzania is one of the countries participating in the Better Medicines for Children project with the aim of addressing current gaps in the availability of children s medicines in order to improve access. As part of the Better Medicines for Children project activities in Tanzania, a survey of the availability and price of key paediatric medicines was undertaken. The survey is part of a series of baseline assessments being undertaken to understand the current situation concerning access to essential medicines for children. Once the situation has been assessed, it will be possible to advocate for changes that will benefit children and their families and lead to measurable improvements in health outcomes. 1.2 Country background The United Republic of Tanzania is a union between Tanganyika (Tanzania Mainland) and Zanzibar. It has a total area of 945 000 square kilometres of which 883 000 is land; 881 000 square kilometres on the mainland and 2000 square kilometres on Zanzibar. The population of Tanzania rose from 17.5 million in the 1978 census to 34.6 million (mainland: 33 584 078 and Zanzibar: 984 531) in the 2002 census. The 2002 census also showed that 80% of the population lived in rural areas, women of childbearing age and children under five years of age each represented 20% of the population, and there were approximately 1.3 million infants in the country. At an annual growth rate of 2.9%, it is projected that the total population in 2010 could now be 42.95 million. With a gross domestic product per capita of US$354 (2007), Tanzania is considered a low income country. Annual gross domestic product growth in 2007 and 2008 were 7.1% and 7.5%, respectively, however it went down to 6.0% in 2009, partly due to the global financial crisis (4). The country s economy is based mainly on agriculture and tourism, which accounts for 75 78% of the total export earnings but meets only one Assessment of the prices and availability of medicines for children in Tanzania -- Page 2

third of Tanzaniaʹs import requirements. According to 2006 estimates, Tanzania s unemployment rate is approximately 11%,(5) and 34% of the country s population is living below the poverty line (2007 estimate). Total health expenditure per capita was US$ 45 in 2006, significantly lower than the regional average of US$ 148 (6). Government spending on public health was only US$ 6 per capita in 2001 but has now reached around US$ 12, which is still below the Abuja target of US$ 15. In spite of developments made after independence and the favourable economic growth realized recently, Tanzania s social indicators, which include health, are still below those of other countries. In the health sector, some of the causes include: shortfalls in the annual health sector budget allocations; increased demand for health care due to expanding growth of the population and changes in disease patterns; increased essential health care costs; increased morbidity and mortality due to HIV/AIDS. In an effort to strengthen the pharmaceutical sector, the government endorsed the first National Drug Policy,(7) Standard Guidelines, and National Essential Drug List for Tanzania in 1991. The National Drug Policy established a master plan to improve the pharmaceutical sector between 1992 and 2000, with clear objectives, strategies, time frames and budgets required to achieve development in key areas. The Standard Guidelines and National Essential Drug List for Tanzania were later revised in 1997, and the current version was reviewed in 2007 (8). The aims of the guidelines were to provide health workers with a limited number of medicines and a set of treatment protocols covering diseases and conditions found in the country so that prescribing and dispensing practices can be rationalized. The Standard Guidelines and National Essential Drug List for Tanzania also help in medicine quantification, procurement and supply to achieve better outcomes for patients, an important objective of all health care systems. The Ministry of Health and Social Welfare s policy requires all health workers in government, private and nongovernmental organization facilities to strictly adhere to the Standard Guidelines and mandates that all procurement, labelling, prescribing and dispensing should be by generic name as much as possible. 1.3 The rational use of paediatric medicines Surveys undertaken by the World Health Organization have found that one third of patients around the world die of irrational drug use rather than of the disease itself (9). The irrational use of medicines is a significant issue in Tanzanian health facilities. Although previous studies on rational prescribing of medicines have found that the average number of medicines per prescription ranged from 1.8 to 2.9 in public facilities and from 1.8 to 2.8 in the church owned primary health facilities,(10,11,12,13,14) there was a high rate of irrational antibiotic and injection use, particularly in the private sector (12). Similar findings have been observed in churchowned primary health facilities (14). However, in almost all the studies generic Assessment of the prices and availability of medicines for children in Tanzania -- Page 3

prescribing was very high ( 80%) with the exception of one study that reported rates of generic prescribing between 48 52%. Many studies have been done to document drug use patterns. These studies indicate that over prescribing, multi drug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems of irrational drug use by prescribers, as well as consumers. Improving drug use would have important financial and public health benefits (15). 1.4 Cost sharing in Tanzania In 1993, the Government of Tanzania developed a programme for the implementation of cost sharing in health services. The main objective was to generate additional resources to compliment government budgetary allocations. By January 1994, user fees (cost sharing and drug capitalization) had been introduced for health services. In addition, community health funds were introduced at the district level and in 2001, a national health insurance fund was established mainly for civil servants. The insurance fund refunds institutions (not individuals) through a fee forservice mechanism, which began operating in October 2001. Beneficiaries of the systems are public health facilities, faith based health facilities and a few private pharmacies. Through the insurance fund, accredited health facilities provide services and send bills to the fund for settlement. However, not all health facilities are registered with the insurance fund. The medicine prices to be refunded are set by the insurance fund. To uphold its policy of equity, universal access and affordability, the government provides exemptions and waivers within the cost sharing programme. According to the programme, exemptions are defined as statutory entitlements to free public health services, and waivers are conditional temporary entitlements for those classified as unable to pay (as determined by the management of the health facilities as stipulated in the implementation guidelines). Categories specified for exemption are: maternity and child health services in all grade III services; children under five, and the elderly (>60 years of age); patients with the following medical problems: tuberculosis, leprosy, hypertension, diabetes, mental illness, cancer and HIV/AIDS, and epidemic diseases such as cholera, meningitis, plague, etc. 1.5 Medicine procurement The pharmaceutical procurement, supply and distribution systems are handled by the Medical Stores Department in the public sector, and by private pharmaceutical wholesalers in the private sector. The Medical Stores Department receives orders from all public health facilities and nongovernmental organization facilities and procures only those medicines registered by the Tanzania Food and Drugs Authority. Procurement is conducted through a competitive tender system. Assessment of the prices and availability of medicines for children in Tanzania -- Page 4

Problems within the public supply system include poor transportation and infrastructure, which affects the distribution process. Currently there is only a pull system based on requisition, as the push system based on a medicine kit was phased out in 2007. In the pull system, drugs are ordered through requisitions to the Medical Stores Department according to both the needs of the facility and the availability of funds provided by the Ministry of Health and Social Welfare. This system serves all levels of health facilities. 1.6 Medicine prices The rise of new diseases such as HIV/AIDS, and increasing resistance to medicines of potentially fatal diseases such as malaria and tuberculosis, all contribute to high expenditures on medicines. In high income countries, governments spend about 10% of their health budgets on medicines, while in low income countries, medicines account for 25% of government health budgets (16). Tanzania spends approximately 15% of the total health budget on medicines. Pricing of medicines is affected by many factors at the international level. Pharmaceutical companies infrequently implement equitable pricing selling the same medicines at different prices in different countries in accordance with people s purchasing power. Surveys in developing countries have shown that some commonly used medicines are more expensive than in industrialized countries. Changes in trade regulations and particularly rules relating to intellectual property, such as patent rights, may also affect international prices and availability of medicines (17). The high price of medicines is one of the most important obstacles to access to health services. National policies on medicine pricing and procurement strategies are required to ensure that medicines are affordable to the majority of the population. Policies are also needed to improve health infrastructures, ensure equitable and sustainable financing and promote the rational use of medicines. The difficulty in finding reliable information on the availability and price of paediatric medicines hinders governments from constructing sound medicine pricing policies or evaluating their impact. It also makes it difficult for governments to evaluate whether their expenditure on medicines takes into account medicines for children and whether it is comparable to that of other countries at a similar stage of development. Furthermore, those responsible for purchasing medicines cannot negotiate cheaper prices because they have no sound price data from which to start their negotiations. The World Health Organization and Health Action International have developed medicine price indicators, which report the sales prices of originator brands and generically equivalent medicines in comparison with international reference prices. The low availability of medicines for children in health facilities, including public, private (retail pharmacies) and mission (nongovernmental organization) facilities, is also of concern. Information on the level of availability and prices of childrenʹs medicine formulations are currently lacking in Tanzania. Although some medicines for children are included on the National Essential Medicines List for Tanzania and in Assessment of the prices and availability of medicines for children in Tanzania -- Page 5

Standard Guidelines, the availability of these medicines in the health facilities is unknown. The findings from the study will assist the government in monitoring the impact of policies relating to medicine pricing, the effect of the introduction of the National Essential Drug List for children, the availability of essential medicines for children in health facilities, and the influence of Medical Stores Department policies related to procurement and supply. It will also assist the government in procuring medicines for children and in negotiating equitable medicine prices based on ability to pay. The results will also help government and nongovernmental organizations to understand the affordability of essential medicines for children in different segments of the health care sector. Thus, there is a need to determine the level of availability of children s medicines in health facilities and the prices that parents and caretakers are paying to purchase treatments. Knowledge and awareness of availability and prices are important so that appropriate measures and action can be taken to improve access. The aim of this study is therefore to assess the availability and price of medicines for children in health facilities in Tanzania. 2. OBJECTIVES 2.1 Broad objective To survey the availability and prices of fifty children s medicines used to treat the spectrum of illnesses that contribute to the disease burden in children in Tanzania. 2.2 Specific objectives The specific objectives of the study were to answer the following questions: What is the availability of paediatric medicines in the public, private and nongovermental organization sectors? Is the public sector purchasing paediatric medicines efficiently in comparison with international reference prices? What is the price of highest and lowest priced generic paediatric medicines in the public, private and nongovermental organization sectors, and how does this compare with international reference prices? How affordable are medicines for the treatment of childrenʹs common conditions for people with low income? Are there therapeutic committees in the health facilities? Assessment of the prices and availability of medicines for children in Tanzania -- Page 6

3. METHODOLOGY The methodology described in the World Health Organization manual titled Measuring medicine prices, availability, affordability and price components, 2nd edition, (16) was used as a guide to collect data and analyse medicines prices in a standardized way. It involves a systematic facility based survey to collect accurate data and reliable information on a selected number of medicines. It is characterized by: a standard list of medicines for comparison; a systematic sampling process; use of international reference prices; comparison of highest and lowest priced generic equivalent medicines; sector comparisons (e.g. public, private and mission); and affordability estimations. A timetable for the survey was prepared (see Annex 1). 3.1 Description of the study areas The survey assessed the prices and availability of medicines in six geographical areas in Tanzania: the capital city Dar es Salaam and the five other administrative regions of Manyara, Mbeya and Mtwara, Shinyanga and Tabora, representing the northern, western, central and southern areas of the country, respectively (Figure 1). These regions are quite different economically. Figure 1 A map of Tanzania showing the six regions surveyed in the study: A- Dar es Salaam, B-Mtwara, C-Mbeya, D- Manyara, E-Shinyanga and F-Tabora The selection of study areas also took into account the Medical Stores Department zones in these regions, which provide a good representation of the country. The lists of health facilities were provided by the Ministry of Health and Social Welfare. The Tanzania Food and Drugs Authority provided lists of retail pharmacies and regional pharmacists provided the list of medicine stores and accredited drug dispensing outlets. Assessment of the prices and availability of medicines for children in Tanzania -- Page 7

In each area, the health facilities closest to the consultant/regional/district hospital were chosen for the survey. Since the sampling was representative, the results can be generalized to the country. 3.2 Study population and sampling The study population included the Medical Stores Department, as well as public, private and nongovernmental organization health facilities. Health facilities in the study were sampled out as described below. 3.2.1 National level At the national level the study population included the Medical Stores Department, the only government purchasing agent. 3.2.2 Selection of health facilities The study population included eight public facilities, eight private facilities and eight nongovernmental organizations in each of the six selected regions, resulting in a total of one hundred and forty three health facilities from both urban and rural areas, as shown in Table 2. Table 2: Geographical distribution of the surveyed health facilities (n = 143) Private Retail Public Sector Regions: Pharmacies Faith-based NGOs Dar es Salaam 4 urban 4 rural 4 urban 4 rural 4 urban 4 rural Manyara 3 urban 4 rural 4 urban 4 rural 4 urban 4 rural Mbeya 4 urban 4 rural 4 urban 4 rural 4 urban 4 rural Mtwara 4 urban 4 rural 4 urban 4 rural 4 urban 4 rural Shinyanga 4 urban 4 rural 4 urban 4 rural 4 urban 4 rural Tabora 4 urban 4 rural 4 urban 4 rural 4 urban 4 rural TOTAL 47 48 48 In each region, the public sector sample was composed of one referral hospital, one regional hospital, two district hospitals in urban areas and four primary health facilities (health centre or dispensary) in rural areas surrounding the district hospitals. The private sector sample was composed of four retail pharmacies in urban areas and four medicine stores in rural areas. For the nongovernmental organization four health facilities in urban areas and four in rural areas were selected in the six regions. A list of the facilities included in the sample is provided in Annex 3. 3.3 Survey medicines In medicine price and availability surveys being carried out as part of the Better Medicines for Children project, the list of paediatric medicines to be studied has two components: a list of 22 recommended medicines to be surveyed in all participating countries and states, and a supplementary list of up to 30 medicines chosen from among the commonly used paediatric medicines at national and state level. A list of the 50 medicines included in the survey can be found in Annex 4. Of the 50 medicines included in the survey, 32 can be found in the national essential medicines list. Of these, 19 are expected to be available at dispensaries and higher levels of care, 1 is Assessment of the prices and availability of medicines for children in Tanzania -- Page 8

expected at health centres and higher levels, 11 are expected at district hospitals and above, and 1 is expected at regional and referral hospitals only. For the sake of this study, children range from 0 to 18 years of age. 3.4 Selection and training of survey personnel The area supervisors, data collectors and data analyst were selected from teaching institutions, the Ministry of Health and Social Welfare and from among regional pharmacists in the surveyed regions. Survey personnel selected were familiar with the medicines, the geographical areas for data collection, and data analysis. The training of area supervisors, data collectors and data analyst took place at the Belinda Hotel, Dar es Salaam, Tanzania for three days from 10 12 November 2010. Each of the six regions in the study had a survey team consisting of a data collector and an area supervisor. The training workshop covered the following topics: a) Purpose of the Better Medicines for Children project and the medicine availability and price survey b) Instructions on how to conduct the survey c) How to collect data d) Introduction to the list of medicines in the survey e) Completing the field survey forms during data collection f) Data entry and verification On the second day of the training workshop, a pilot test of data collection, entry and analysis was conducted. At the end of the training, the data collectors and their supervisors departed to their different stations to complete the survey. 3.5 Methods of data collection Face to face interviews using structured survey forms provided in Annex 2 were adopted in the collection of data. 3.5.1 Data collection at the national level The survey manager collected prices from the Medical Stores Department, the only government procurement agent. 3.5.2 Data collection at health facilities Data was collected between 14 and 24 November 2010. A total of 47 public, 48 private and 48 nongovernmental organization health facilities were surveyed. At each health facility level, and for each medicine, two products were monitored, namely the highest priced generic and lowest priced generic medicine available at the facility. For the purposes of the survey, a generic medicine is defined as a Assessment of the prices and availability of medicines for children in Tanzania -- Page 9

pharmaceutical product usually intended to be interchangeable with the originator brand product, manufactured without a licence from the originator manufacturer and marketed after the expiry of patent or other exclusivity rights. When a target product was available, the price of the pack was recorded on the data collection form. In cases where medicines were provided free of charge, only availability was recorded. The supervisor and the data collector in each region travelled together and at the end of the day, the supervisor reviewed the data collection forms and signed them. Wherever there was any doubt, a price seemed too high or some data were missing, the facility was revisited the next day before visiting other facilities. Initially the data collectors were instructed to collect the data for 8 facilities for each sector in the region. However, some of these facilities had less than 50% of the medicines, therefore, back up facilities were visited and this resulted in an increase of the number of facilities in the sample. 3.6 Data entry and analysis The data analyst used a computerized Excel workbook, provided as part of the World Health Organization/Health Action International survey tools, to enter and analyze the data. The exchange rate (US$ 1 to TShs 1485.0000) was entered in the international medicine reference price data page. Medicine unit price data were entered in the field consolidation pages for procurement, public sector, private sector and other sector (nongovernmental organizations). The workbook automatically summarized and compared the data by sector and by medicine. To estimate treatment affordability, the monthly wage of the lowest paid unskilled government worker (TShs 135 000 or US$ 90.91) and the median medicine prices found at the sample facilities were used to calculate the number of days wages needed to purchase standard courses of treatment. To ensure the accuracy of the data, the area supervisors counterchecked all data entered to make sure that there were no errors in data entry. During this exercise data entry errors were corrected. In addition, the procedure of double entry was followed so as to eliminate data entry errors, which were left undetected when using the normal counterchecking method. 3.7 Ethical considerations Since the survey was designed to be completed in collaboration with the Ministry of Health and Social Welfare, there was no need to apply to the ethical committee for clearance to conduct the survey. However, permission was sought beforehand from the Ministry of Health and Social Welfare regional and district authorities to receive permission to work in their areas. All data collectors were given an introductory letter to present to the heads of facilities. 3.8 Expected results Data collected during this survey will give the Ministry of Health and Social Welfare an indicative picture of the current availability and prices of children s medicines in public, private and nongovernmental organization (mission) health facilities. This will enable the government to effectively make decisions that will benefit children Assessment of the prices and availability of medicines for children in Tanzania -- Page 10

especially in the anticipation of scaling up antiretroviral treatment in accordance with the Tanzanian health plans. The Ministry of Health and Social Welfare will also be able to determine whether children s medicines are available and affordable to this community. Expected long term outcomes of the use of standard data collection tools and the survey results include: forming a basis for ongoing collaboration between the African countries participating in the Better Medicines for Children project and the World Health Organization to improve the availability of medicines to children; providing a mechanism for monitoring changes in the availability and price of childrenʹs medicines over time and helping identify country specific supply and price problems that might be addressed by specific interventions. Cross country comparisons may also allow the identification of issues relevant for action across the region. 4. RESULTS The results of this study will be presented according to the following sub topics: Availability of medicines in the public, private and nongovernmental organization sectors Intersectoral comparison of medicine availability Public procurement sector prices Facility prices in the public, private and nongovernmental organization sectors Intersectoral comparison of medicine prices Affordability to patients Annex 5 contains the percent availability and median price ratios for individual medicines for the public, private and nongovernmental organization sectors. 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 ʹbasketʹ of medicines surveyed. The prices in this study are expressed as ratios relative to a standard set of international reference prices: price ratio (MPR) = median local unit price international reference unit price The international reference price serves as an external standard for evaluating local prices. The prices are expressed in this way so as to facilitate national and international price comparisons. The median price ratio is an expression of how much greater or less the local medicine price is than the international reference price. For example, a median price ratio of 2 would mean that the local medicine price is twice that of the international reference price. Assessment of the prices and availability of medicines for children in Tanzania -- Page 11

The median price ratio results in this survey are based on reference prices taken from the 2009 Management Sciences for Health International Drug Price Indicator Guide (18). These reference prices are the medians of recent procurement prices offered by for profit and notfor profit suppliers to international not for profit agencies for generic products. As averages can be skewed by outlying values, median values are generally used in the presentation of price results and discussion as they are a better representation of the midpoint. The median is the value that divides the distribution in half. Results are also reported by quartile. A quartile is a percentile rank that divides 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 (the range including the values that are up to 25% higher or down to 25% lower than the median) is called the inter quartile range. 4.1 Availability of medicines in the public, private and nongovernmental organization sectors The availability of paediatric medicines assessed in this survey was low in all sectors. Public sector The mean availability of the lowest priced generic medicines in the basket was found to be 32.0% with wide variation observed across individual medicines (SD 32.0%). Mean availability of medicines on the National Essential Drug list for Tanzania was higher at 45.3%. The following generic medicines had particularly high availability (80% and above): salbutamol inhaler (100% at level D facilities), artemether + lumefantrine (80.9%), benzylpenicillin injection (87.2%), lamivudine tablets (85.7%), Prednisolone tablets (85.7%) and quinine injection (85.1%). The following generic medicines had particularly low availability (20% and below): albendazole suspension (4.3%), amoxicillin + clavulanic acid suspension/dispersible tablet (0% and 2.1%), beclometasone inhaler (0%), carbamazepine suspension/chewable tablet (both 0%), co trimoxazole tablet (0%), diazepam injection and rectal solution (10.6% and 2.1%), digoxin tablet (0%), ferrous sulphate suspension (0%), gentamicin eye/ear drops (10.6%), isoniazid scored tablet (2.1%), morphine tablets and suspension (0% and 0%), nalidixic acid (0%), Phenobarbital injection (12.8%), phenytoin suspension and chewable tablet (both 0%), pyrazinamide tablet (6.4%), rifampicin suspension (0.0%), salbutamol tablet (2.1%), and vitamin A capsules (4.3%). The availability of children medicines was not significantly different between rural and urban areas. Assessment of the prices and availability of medicines for children in Tanzania -- Page 12

Private sector The mean availability of generic medicines in the basket was found to be 34.4% with wide variation observed across individual medicines (SD 34.6%). The following generic medicines had particularly high availability (80% and above): albendazole chewable tablet (100%), amoxicillin oral suspension (93.8%), Co trimoxazole suspension (93.8%), gentamicin eye/ear drops (81.3%), nystatin drops (85.4%), and paracetamol suspension (97.9%). The following generic medicines had particularly low availability (20% and below): amoxicillin + clavulanic acid dispersible tablet (10.4%), beclometasone inhaler (6.3%), carbamazepine suspension and chewable tablet (6.3% and 0%), co trimoxazole tablet (0%), diazepam rectal solution and injection (each 0%), digoxin tablet (0%), Ferrous sulphate suspension (2.1%), gentamicin injection (6.3%), morphine tablet and suspension (each 0%), nalidixic acid (0%), phenobarbital injection (2.1%), phenytoin suspension and chewable tablet (each 0%), and salbutamol tablet (0%). Highest price generics were found for 10 medicines, indicating that for these products private sector outlets are stocking at least two generic equivalents. However availability of these medicines was less than 20% in all cases except paracetamol suspension (31.3%) and albendazole suspension (27.1%). Medicines were more available in urban facilities than in rural facilities and the overall means of number of drugs available, between rural and urban health facilities is statistically significant. Nongovernmental Organization sector The mean availability of generic medicines in the basket was found to be 32.1% (SD 32.1%) with wide variation observed across individual medicines. The following generic medicines had particularly high availability (80% and above): amoxicillin oral suspension (87.5%), benzylpenicillin suspension (87.5%), co trimoxazole suspension (87.5%), hydrocortisone injection (81.3%), paracetamol suspension (83.3%), and quinine injection (89.6%). The following generic medicines had particularly low availability (20% and below): amoxicillin + clavulanic acid suspension (8.3%), amoxicillin + clavulanic acid dispersible tablet (2.1%), beclometasone inhaler (0%), carbamazepine suspension and chewable tablet (2.1% and 0%), co trimoxazole tablet (0%), diazepam rectal solution and injection (0% and 4.2%), digoxin tablet (0%), ferrous sulphate suspension (0%), gentamicin injection (18.8%), isoniazid scored tablet (0%), lamivudine suspension (16.7%), morphine tablet and suspension (each (0%), nalidixic acid (0%), phenobarbital injection (16.7%), phenytoin suspension and chewable tablet (each 0%), pyrazinamide tablet (0%), rifampicin suspension (0%), salbutamol tablet (0%), and vitamin A capsule (4.2%). The availability of children medicines in nongovernmental organization facilities was not statistically significantly different between rural and urban areas. Assessment of the prices and availability of medicines for children in Tanzania -- Page 13

4.2 Cross-sector comparison of medicine availability Figure 2 shows the distribution of individual medicine availability in the public, private and nongovernmental organization sectors. Of the 50 medicines surveyed, 13, 12 and 15 were not available in any of the health facilities in the public, private and nongovernmental organization sectors, respectively, while 13, 11 and 11 medicines were available in 1 24% of facilities. Only 7, 9 and 7 medicines were available in 75% or more of the public, private and nongovernmental organization health facilities, respectively. Figure 2: Percentage availability of 50 target medicines in the three sectors 16 15 14 13 13 12 12 11 11 12 Number of medicines 10 8 6 7 10 6 6 5 7 9 7 public private NGO 4 2 0 0 1 to 24 25 to 49 50 to 74 75 to 100 % Availability Table 3 shows the availability of individual medicines by therapeutic class across the public, private and nongovernmental organization sectors. Oral rehydration solution for the treatment of diarrhoea showed moderate availability, ranging from 57.4% in the public sector to 72.9% in the private sector. However, dispersible zinc tablets were consistently less available (29.8%, 43.8%, and 33.3% in the public and private and nongovernmental organization sectors, respectively). Antibiotics had variable availability depending on the medicine and sector surveyed. For example, benzylpenicillin injection had reasonable availability in all three sectors (87.2%, 66.7% and 87.5% in the public, private and nongovernmental organization sectors, respectively). Amoxicillin suspension had high availability in private and nongovernmental organization facilities, but was only available in 55% of the public facilities surveyed. Ceftriaxone injection had poor availability in all sectors (57.1%, 25.0% and 22.9% in the public, private and nongovernmental organization sectors, respectively), as did gentamicin injection (21.3%, 6.3% and 18.8% in the public, private and nongovernmental organization sectors, respectively). For antiasthmatics, beclometasone inhaler was not available in any public or nongovernmental facilities, and was only available in 6.3% of private facilities. While salbutamol inhaler had higher availability in all three sectors, it should be noted that it is listed on the national essential medicines list as a level D medicine (regional and referral Assessment of the prices and availability of medicines for children in Tanzania -- Page 14

hospitals) and as such availability in the public sector only reflects availability at this level of care. Opioid analgesics, namely morphine suspension and tablets, were not available in any facilities in any sector. Anticonvulsants also showed consistently low availability in all sectors. With the exception of phenobarbital injection in the public sector, the availability of the anticonvulsants surveyed was consistently less than 20% in all sectors, and was often 0%. Table 3: Analysis of medicine availability (%) by therapeutic class Therapeutic class Medicine Name Strength Public sector Private sector NGO sector Anemia Ferrous sulphate suspension 30mg/5ml 0.0% 2.1% 0.0% Anthelmintic Albendazole chewable tablet 200mg 63.8% 100.0% 66.7% Anthelmintic Albendazole suspension 100mg/5ml 4.3% 79.2% 31.3% Antiasthmatic Beclometasone inhaler 100mcg/dose 0.0% 6.3% 0.0% Antiasthmatic Epinephrine injection 1mg/ml 59.6% 20.8% 60.4% Antiasthmatic Hydrocortisone injecton 100mg 44.7% 56.3% 81.3% Antiasthmatic Prednisolone tab 5mg 85.7% 77.1% 64.6% Antiasthmatic Salbutamol inhaler 100 mcg/dose 100%* 62.5% 25.0% Antiasthmatic Salbutamol tab 2mg 2.1% 0.0% 0.0% Antibiotic Amoxicillin suspension 125mg/5ml 55.3% 93.8% 87.5% Antibiotic Amoxicillin+clavulanic acid susp125mg+31mg/5ml 0.0% 22.9% 8.3% Antibiotic Amoxicillin+clavulanic acid tab 250mg+125mg 2.1% 10.4% 2.1% Antibiotic Benzylpenicillin injection 5MU (3g) 87.2% 66.7% 87.5% Antibiotic Ceftriaxone injection 250mg/vial 57.1% 25.0% 22.9% Antibiotic Chloramphenicol injection 1gm/vial 46.8% 33.3% 52.1% Antibiotic Co - trimoxazole tab 20mg+100mg 0.0% 0.0% 0.0% Antibiotic Co-trimoxazole suspension 8+40 mg/ml 61.7% 93.8% 87.5% Antibiotic Erythromycin oral suspension 125mg/5ml 38.3% 75.0% 70.8% Antibiotic Gentamicin eye/ear drops 0.3% 10.6% 81.3% 56.3% Antibiotic Gentamicin injection 10mg/ml 21.3% 6.3% 18.8% Antibiotic Nalidixic acid tab 250mg 0.0% 0.0% 0.0% Anticonvulsant/antiepileptic Carbamazepine suspension 100mg/5ml 0.0% 6.3% 2.1% Anticonvulsant/antiepileptic Carbamazepine tab chewable 100mg 0.0% 0.0% 0.0% Anticonvulsant/antiepileptic Diazepam injection 2mg/2ml 10.6% 0.0% 4.2% Anticonvulsant/antiepileptic Diazepam rectal solution 2.5mg/ml 2.1% 0.0% 0.0% Anticonvulsant/antiepileptic Phenobarbital injection 200mg/ml 28.6% 2.1% 16.7% Anticonvulsant/antiepileptic Phenytoin suspension 25or30mg/ml 0.0% 0.0% 0.0% Anticonvulsant/antiepileptic Phenytoin tab chewable 50mg 0.0% 0.0% 0.0% Antidiarrheal Oral rehydration solution to make 1L 57.4% 72.9% 68.8% Antidiarrheal Zinc dispersible tablet 20mg 29.8% 43.8% 33.3% Antifungal Nystatin drops 100,000IU/ml 21.3% 85.4% 60.4% Antimalarial Artemether+lumefantrine dispe 20mg+120mg 80.9% 18.8% 52.1% Antimalarial Quinine injection 600mg/2ml 85.1% 66.7% 89.6% Antituberculosis Isoniazid scored tab 50mg 2.1% ** 0.0% Antituberculosis Pyrazinamide tab 400mg 6.4% ** 0.0% Antituberculosis Rifampicin suspension 100mg/5ml 0.0% ** 0.0% ARV Lamivudine (3TC) tab 150mg 85.7% ** 33.3% ARV Lamivudine suspension 50mg/5ml 42.9% ** 16.7% ARV Nevirapine syrup 50mg/5ml 71.4% ** 25.0% Cardiovascular Digoxin tab 62.5 µg 0.0% 0.0% 0.0% Cardiovascular Furosemide injection 20mg/2ml 71.4% 27.1% 52.1% NSAIMs Paracetamol suspension 24 or 25 mg/ml 51.1% 97.9% 83.3% Opioid Analgesic Morphine oral suspension 10mg/5ml 0.0% 0.0% 0.0% Opioid Analgesic Morphine tab immed release 10mg 0.0% 0.0% 0.0% Other Canula 24g 23.4% 22.9% 52.1% Other MRDT (Rapid Diagnostic Test for Falciparum malar 23.4% 0.0% 16.7% Other Normal saline 0.9% 57.4% 56.3% 75.0% Other Ringers soln - sodium lactate comp. 75.0% 43.8% 72.9% Vitamins Vitamin A cap 50,000 IU (15mg) 4.3% 35.4% 4.2% Vitamins Vitamin K1 injection 10mg/ml 28.6% 20.8% 22.9% * Availability at Level D health facilities. ** Excluded as not provided through the private sector. Assessment of the prices and availability of medicines for children in Tanzania -- Page 15

Public procurement sector prices Of the 50 medicines surveyed, only 27 were in stock at the time of assessment. Public procurement prices for lowest priced generics were found on average to be 0.80 times the international reference price, which means that Tanzania is procuring medicines at prices below those available on the international market. However, within the basket of medicines surveyed, there were three medicines where the price was substantially greater than the international reference price. These medicines were phenobarbital injection (MPR = 2.38), gentamicin injection (MPR = 3.14) and epinephrine injection (MPR = 1.73). Highest price generics were not found. That is, only one generic product was found for each medicine, and this was taken as the lowest priced generic. 4.3 Facility prices in the public, private and nongovernmental organization sectors Public sector As mentioned earlier, Tanzania practices a cost sharing system for charging patients. However, its implementation varies; some patients pay a flat rate for total treatment and other services, while others do not pay anything. Out of 47 public facilities surveyed 18 facilities were either charging flat rate or giving free medicines. The majority of facilities giving free medicines were primary health care facilities including health centres and dispensaries receiving drugs from the Medical Stores Department. Medicines for conditions like mental illness, epilepsy, tuberculosis, leprosy, HIV/AIDS and other chronic conditions were given free. Children under five years of age also receive free treatment including medicines and consultations. Therapeutic committees were found in only 10 health facilities. The data collector was shown the current minutes of the committee to confirm that they are functioning. Of the 50 study medicines, only 12 had sufficient availability to enable calculation of median price ratios. The lowest priced generic medicines were found to have a median MPR for the basket of 0.96. The price ratios for lowest priced generic medicines within the basket ranged from 0.17 for artemether + lumefantrine dispersible tablet to 13.41 for albendazole chewable tablet. No highest price generics were found in the public sector. That is, only one generic product was found for each medicine at each facility, and this was taken as the lowest priced generic. More than half (7 of 12) of the lowest priced generic medicines had large price variations across individual facilities. Medicines for which the 25th and 75th percentiles of the price ratio varied by 100% or more were albendazole chewable tablet, oral rehydration salts, hydrocortisone injection, furosemide injection, ceftriazone injection, chloramphenicol injection, and benzyl penicillin injection. Assessment of the prices and availability of medicines for children in Tanzania -- Page 16

Private sector Lowest price generics were found to have a median MPR of 2.22 (n=22) for the medicines in the basket. However, within the lowest price generics basket the median price ratios ranged from 1.49 for salbutamol inhaler to 14.9 for albendazole chewable tablets. One quarter of the lowest price generic medicines in the basket had median price ratios greater than 3.66, that is, prices that were nearly four times higher than international reference prices. These products were albendazole chewable tablets (MPR=14.9), albendazole suspension (MPR=3.74), epinephrine injection (MPR=4.33), vitamin K injection (MPR=5.33), and vitamin A capsules (MPR=8.47). Figure 3 below shows the numbers of medicines with median price ratios for the lowest priced generics in the private sector varying from less than 1 to over 10 times international reference prices. One of the medicines (albendazole chewable tablet) was found to have a price greater than 10 times the international reference price. Three of the medicines were found to have prices between 5 and 10 times the international reference price while 18 of the medicines had prices between 1 and 5 times the international reference price and none of the medicines were below the international reference price. Figure 3 price ratios of lowest price generic medicines in the private sector 20 18 Number of medcines 15 10 5 0 3 1 0 < 1 1 to < 5 5 to < 10 > 10 price ratio Of the 10 highest priced generic medicines found, 4 had sufficient availability to enable calculation of median price ratios: albendazole chewable tablet (MPR=89.39), albendazole suspension (MPR=6.36), paracetamol suspension (MPR=4.32) and salbutamol inhaler (MPR=1.85). The 4 highest priced generic medicines prices were found to be on average 96% more expensive than the corresponding lowest priced generics (Table 4). Assessment of the prices and availability of medicines for children in Tanzania -- Page 17

Table 4: Number of times more expensive, highest priced vs. lowest priced generics Medicine Albendazole chewable tablet 200 mg Albendazole suspension 100 mg/5ml Paracetamol suspension 24 or 25 mg/ml Salbutamol inhaler 100 mcg/dose Price Ratio MPR HPG /MPR L Highest priced Lowest priced PG generic generic 89.39 14.90 6.0 6.36 3.74 1.7 4.32 1.73 2.5 1.85 1.49 1.3 Overall, lowest priced generic medicines prices showed little variability across private sector medicine outlets. Medicines for which the 25th and 75th percentiles of the price ratio varied by 100% or more were epinephrine injection, vitamin K injection and prednisolone tablet. Medicines with no price variation between the 25th and 75th percentiles of the price ratio were albendazole chewable tablet, furosemide injection, hydrocortisone injection and zinc dispersible tablet. Nongovernmental Organization sector As in public sector health facilities, some nongovernmental organization health facilities were practicing a cost sharing system. Some nongovernmental organization health facilities in the regions were also found to charge flat rates for services. Patients were paying flat rates or receiving free medicines in about 14% of the facilities surveyed. These included drugs for conditions such as epilepsy, tuberculosis, leprosy, HIV/AIDS and other chronic conditions. Children under five years receive free medical services. Six health facilities had a functioning therapeutic committee confirmed by the availability of the recent minutes of the committee. Lowest priced generics were found to have a median MPR of 2.41 (n=21) for the medicines in the basket. However, within the lowest priced generics basket the median price ratios ranged from 0.42 for artemether + lumefantrine dispersible tablets to 14.9 for albendazole chewable tablet. As in the public sector, no highest price generics were found. That is, only one generic product was found for each medicine at each facility, and this was taken as the lowest priced generic. More price variation was observed across nongovernmental organization facilities than across private sector facilities. Table 5 shows medicines for which the 25th and 75th percentiles of the price ratio varied by 100% or more. Assessment of the prices and availability of medicines for children in Tanzania -- Page 18

Table 5: Price variation across nongovernmental organization medicine outlets Medicine Price Ratio % difference, 25 th and 75 th 25 th 75 th percentile percentile percentile Epinephrine injection 1.73 1.73 2.46 100% Zinc dispersible tablet 2.33 1.73 2.59 100% Chloramphenicol injection 4.57 3.05 4.57 104% Phenobarbital injection 3.74 3.74 5.61 104% Oral rehydration salts 1.20 0.97 1.48 150% Prednisolone tablet 1.33 1.13 1.77 150% Albendazole chewable tablet 2.16 1.51 2.49 167% Ceftriaxone injection 1.71 1.28 2.13 169% Gentamicin injection 2.41 1.84 3.21 264% Artemether + lumefantrine dispersible tablet 2.63 1.78 3.45 635% 4.4 Cross-sector comparison of patient prices Public sector patient prices for the lowest priced generics were on average 19.4% higher than the public sector procurement prices (n=10 medicines). In three cases (co trimoxazole suspension, chloramphenicol injection, erythromycin suspension) procurement prices were double those observed in public facilities (Figure 3). In other cases patient prices were comparable to, or significantly higher than, procurement prices. Albendazole chewable tablets cost 16 times the procurement price at health facilities. Assessment of the prices and availability of medicines for children in Tanzania -- Page 19

Figure 4: Comparison of median price ratios between public procurement prices and public sector facility (patient) prices 3.0 2.5 2.0 price ratio 1.5 1.0 0.5 0.0 Co-trimoxazole suspension Chloramphenicol injection Erythromycin oral suspension Hydrocortisone injecton Oral rehydration salts Benzylpenicillin injection Public procurement (n=1) Public sector facilities (n=47) Epinephrine injection Ceftriaxone injection Prednisolone tab Albendazole chewable tablet Private sector patient prices for lowest priced generics were one and a half times (154.9%) higher than public sector patient prices (n=12 medicines). The difference in price between medicines in the public sector and the private sector is shown in Table 6. The highest price difference was for artemether + lumefantrine, co trimoxazole suspension, chloramphenicol injection, and erythromycin suspension. Some medicines with high price ratios in the private sector were not widely available in the public sector (Table 7). Medicines with an availability of less than 10% include albendazole suspension, amoxicillin + clavulanic acid suspension, and vitamin A capsules. Assessment of the prices and availability of medicines for children in Tanzania -- Page 20

Table 6: Price difference between medicines found in both public and private sectors price ratio Medicine Public sector Private sector Ratio private: public sector Albendazole chewable tablet 13.41 14.90 1.1 Prednisolone tablet 2.57 3.42 1.3 Epinephrine injection 2.54 4.33 1.7 Ceftriaxone injection 1.53 2.91 1.9 Benzylpenicillin injection 1.05 2.10 2.0 Furosemide injection 2.88 7.19 2.5 Hydrocortisone injection 0.87 2.16 2.5 Oral rehydration salts 0.83 2.48 3.0 Erythromycin oral suspension 0.35 1.77 5.0 Chloramphenicol injection 0.36 1.87 5.3 Co-trimoxazole suspension 0.37 2.41 6.5 Artemether + lumefantrine dispersible tablet 0.17 1.70 10.0 Table 7: Medicines with median price ratios > 2 in the private sector and their corresponding availability in the public sector price ratio Private sector Availability Public sector Medicine Amoxicillin + clavulanic acid suspension 2.28 0.0% Albendazole suspension 3.74 4.3% Vitamin A capsule 8.47 4.3% Vitamin K injection 5.33 28.6% Furosemide injection 7.19 71.4% Prednisolone tablet 3.42 85.7% Ceftriaxone injection 2.91 57.1% Hydrocortisone injection 2.16 44.7% Oral rehydration salts 2.48 57.4% Epinephrine injection 4.33 59.6% Co-trimoxazole suspension 2.41 61.7% Albendazole chewable tablet 14.90 63.8% Benzylpenicillin injection 2.10 87.2% Assessment of the prices and availability of medicines for children in Tanzania -- Page 21

Nongovernmental organization sector patient prices for lowest price generics were one and a half times (154.9%) more than public sector patient prices (n=12 medicines). Nongovernmental organization sector prices were slightly more (9.8%) than the private sector prices (n=19 medicines). As observed in the private sector, some of the more expensive medicines in the nongovernmental organization sector were less available in the public sector. Of medicines with median price ratios of over 2 in the nongovernmental organization sector, those with lowest public sector availability are albendazole suspension (4.3%) and gentamicin eye/ear drops (10.6%). 4.5 Affordability Affordability refers to the cost of treatment in relation to people s income. In this survey, the daily wage of the lowest paid unskilled government worker was compared to median medicine prices to estimate the number of days wages needed to purchase a course of treatment. The daily wage of the lowest paid government worker (8 hrs/day) was found to be US$ 3.03 (TShs 4500). Medicines to treat acute conditions were generally affordable in all sectors (Table 8). The cost for the treatment of an acute case of pneumonia (paediatric upper respiratory tract infection) in the nongovernmental organization and private sector was 0.2 days wage, when using co trimoxazole suspension. For malaria, 0.3 days wages are needed to purchase artemether + lumefantrine in the private sector while in the public and nongovernmental organization sectors it is provided by a subsidized price. For diarrhoea, it would cost 0.1 days wage to purchase oral rehydration salts in both private and nongovernmental organization sectors, while zinc dispersible tablets cost 0.7 and 0.4 days wages, respectively. Table 8: Affordability of treating acute conditions: number of days wages the lowest-paid government worker would need to spend to purchase lowest priced generic medicines in the three sectors surveyed Affordability in days' wages Availability (%) (hours) Condition Public Private NGO Public Private NGO Paediatric upper respiratory tract infection Co-trimoxazole 0 0.2 (1.6) 0.2 (1.6) 61.7 93.8 87.5 suspension Malaria Artemether + 0 0.3 (2.4) 0 80.9 18.8 52.1 lumefantrine dispersible tablet Diarrhoea Oral rehydration salts Zinc dispersible tablet 0 0.1(0.8) 0.7 0.1 (0.8) 0.4 57.4 72.9 68.8 Assessment of the prices and availability of medicines for children in Tanzania -- Page 22

Table 9 shows the cost of managing the chronic conditions in the three sectors in terms of daysʹ wages of the lowest paid government worker. For chronic conditions, one month s treatment of asthma with salbutamol inhaler costs the lowest paid government worker 0.9 daysʹ wages if lowest priced generic is used and 1.1 daysʹ wages if the highest priced generic is used. In the nongovernmental organization sector the lowest priced generic costs 0.7 daysʹ wages. Epinephrine costs 0.2 daysʹ wages in the public sector and 0.4 daysʹ wages in each of the private and nongovernmental organization sectors. of hypertension with furosemide costs 0.1 daysʹ wages in both the private and nongovernmental organization sectors. For septicaemia, it takes 0.2, 0.4 and 0.3 days wages to purchase treatment (ceftriaxone injection) in the public, private and nongovernmental organization sectors, respectively. Table 9: Affordability of treating chronic conditions: number of days wages the lowest-paid government worker would need to spend to purchase the lowest priced generic medicines in the three sectors surveyed Affordability in daily wages Availability (%) (hours) Condition/medicine Public Private NGO Public Private NGO Asthma Salbutamol inhaler 0 0.9 (7.2) 0.7(5.6) 14.9 62.5 25.0 Epinephrine 0.2(1.6) 0.4(3.2) 0.4(3.2) 59.6 20.8 60.4 Hypertension Furosemide injection 0 0.1(0.8) 0.1(0.8) 25.5 27.1 52.1 Septicemia Ceftriaxone injection 0.2(0.8) 0.4(0.8) 0.3(0.8) 42.6 25 22.9 5. DISCUSSION The World Health Organization Medicines Strategy describes several challenges which limit access to effective pharmaceutical treatment.(19) These include inequitable health financing mechanisms, unreliable medicine supply, problems associated with the quality of medicines, unaffordable medicine prices and irrational use of medicines. Ensuring access to medicines for children is particularly challenging. For example, many essential medicines do not exist in appropriate dosage forms for children. Even where paediatric dosage forms exist, their supply and/or use can be inhibited by several factors, including the higher shipping costs associated with liquid formulations, a lack of clean water for dissolving powders into liquids, and the difficulty of administering different doses to children of different ages. This study measured the availability and prices of medicines for children in Tanzania and assessed their impact on accessibility and affordability. 5.1 Public sector availability Overall, the availability of medicines for children in the public sector was low. Given that poor and low income families access the public sector more than private or nongovernmental organization facilities, one would hope that the medicines would be available and offered at little or no cost. The observed lack of availability is not in Assessment of the prices and availability of medicines for children in Tanzania -- Page 23

line with the Tanzanian National Medicine Policy, which states the goal to make available to all Tanzanians at all times the essential pharmaceutical products that are of quality, proven effectiveness and acceptable safety at a price that individuals and community can afford, when these are needed to prevent, cure, or reduce illness and suffering. The low availability of medicines in the public sector may be due to the fact that few of the paediatric medicines are licensed and available on the Tanzanian market. Also there is the expectation that some medicines for adults can be split (e.g. halved) to fit childrenʹs dosages. Due to the unavailability of children s formulations, pharmacists and physicians face problems in providing appropriate medicine dosage forms for children by exploring a range of options, which usually involve reformulating adult medicines to make them suitable for children especially those under five years of age. In the public sector, procurement of medicines is governed mostly by the national essential medicine list and standard treatment guidelines where only generic medicines are encouraged. All public facilities are required to purchase medicines from the Medical Stores Department unless a medicine is out of stock. In the Medical Stores Department, only 27 of the 50 medicines surveyed were in stock at the time of the survey. All the medicines were on the national essential medicines list, which demonstrates adherence to the government medicine policy. The four medicines from the essential medicines list that should have been available but were out of stock were amoxicillin suspension, furosemide injection, beclometasone inhaler, and gentamicin eye/ear drops. The low availability of children s medicines in the Medical Stores Department, compared to the target of 100% availability of medicines on the national essential medicines list and standard treatment guidelines, needs to be addressed as this affects the availability of medicines in public sector facilities. This was confirmed by the survey, as the mean availability of the medicines in public facilities was only 32.0% for all survey medicines and 45.3% for medicines on the essential medicines list. The low availability observed in the public sector, where children are exempt from cost sharing, will necessitate parents/caretakers to purchase medicines from other sectors where they are more expensive and possibly unaffordable. However, analysis of the availability of individual medicines by therapeutic class across the public, private and nongovernmental organization sectors showed that some groups of medicines were not available in all sectors. There is a need to review the national essential medicines list to include dosages for children so that Medical Stores Department can include them in its catalogue and purchase them. During the review, the categorization of medicines level should be assessed to ensure conformity with the treatment recommendations within the standard treatment guidelines. For example, salbutamol inhaler is listed only for level D health facilities, regional and referral hospitals, although this treatment is well known to deliver the drug directly to the airways and hence save lives, as indicated in the standard treatment guidelines recommended treatment protocols for asthma. Assessment of the prices and availability of medicines for children in Tanzania -- Page 24

5.2 Public sector prices Out of the 50 items surveyed at the Medical Stores Department only three items had prices over 20% higher than international reference prices. A few products with procurement prices higher than public facility prices were noted and the possible explanation for this are the high costs of emergency shipping, such as air transport. There were no highest price generic products in the Medical Stores Department. This is in line with the government policy of procuring only one generic product. In public sector facilities, overall prices of generics were comparable to international reference prices with a median MPR of 0.96. However, a wide range was observed across individual medicines, with albendazole chewable tablet costing 13.41 times the international reference price. These results are similar to the assessment of medicine prices conducted in 2004, using the same methodology, which found that overall medicines cost 1.33 times their international reference price in the public sector.(20) A large variation between the 25% and 75% percentile price ratios was observed for some medicines, namely albendazole chewable tablet, oral rehydration salts, hydrocortisone injection, furosemide injection, ceftriazone injection, chloramphenicol injection, and benzylpenicillin injection. This is an indication that some facilities were charging low prices while others were charging higher prices (up to 4.8 times more) for the same product. This shows that there are no mechanisms for ensuring price equality in the public sector despite the fact that almost all drugs are purchased from the Medical Stores Department. The large variation in prices observed across public sector facilities can be explained by the fact that the implementation of the cost sharing system for charging patients in the public sector varies between and within the regions. In some facilities, such as the tertiary Muhimbili National Hospital in Dar es Salaam, patients were paying a flat rate of TShs 10 000 (US$ 6.73) for outpatient services, which included consultation, investigation and medicines, and TShs 20 000 (US$13.47) for inpatient services. In other public health facilities, patients in outpatient services were paying TShs 1.000 (US$ 0.67) per prescription, regardless of the number of items on the prescription, while for inpatients the cost was approximately TShs 5 000 (US$ 3.37). Children under five and children above five years of age with chronic diseases like tuberculosis, HIV, and diabetes are among those exempted from paying for medical services, including medicines. The total medicine budget for the public sector for 2003/2004, the year of the first medicine price survey, was US$ 28.5 million. The budgets for 2006/2007, 2007/2008, 2008/2009, 2009/2010, and 2010/2011 were US$ 20.3, 31.5, 36, 33.4 and 40.9 million, respectively. Such increments in the pharmaceutical budget however, have not been enough to meet the national medicine needs. Facilities do have additional funds generated from cost sharing with which they are allowed to purchase medicines outside the Medical Stores Department. The reasons why public facilities continue to face stock outs despite the existence of this ʺstop gapʺ facility are unknown and warrant further study. Assessment of the prices and availability of medicines for children in Tanzania -- Page 25

5.3 Private sector availability and patient prices The mean availability of lowest priced generic medicines in the private sector was only 34.4% for all survey medicines and 46.0% for medicines on the national essential medicines list. Highest price generics were found for 10 medicines, indicating that for these products private sector outlets are stocking at least two generic equivalents. However, availability of these medicines was less than 20% in all cases except paracetamol suspension (31.3%) and albendazole suspension (27.1%). The majority of Tanzanians cannot afford to purchase higher priced products. Therefore, a large number of private retail pharmacies and wholesalers prefer selling one generic medicine rather than offering a choice of products with varying prices. Overall, lowest priced generic medicines in the private sector cost 2.2 times their international reference price. This is reasonable given that reference prices are exfactory, without the inclusion of freight and insurance costs, while facility prices include local distribution costs. However, 18% of medicines had prices of over 5 times the international reference price. Albendazole chewable tablets were the most highly priced in comparison to reference prices; the lowest priced and highest priced generics were priced at 13 and 89 times the international reference prices, respectively. High prices relative to international reference prices may represent high acquisition costs and/or high add on costs in the supply chain (e.g. wholesaler/retailer mark ups, taxes). Overall, lowest priced generic medicines prices showed little variability across private sector medicine outlets. 5.4 Nongovernmental Organization sector patient prices and availability The mean availability of lowest priced generic medicines was only 32.1% for all survey medicines and 43.2% for medicines on the national essential medicines list. Although nongovernmental organization facilities purchase medicines from Medical Stores Department, they had more volume of medicines in stock than the public sector because they do not depend on Ministry of Health and Social Welfare financial allocations for medicines and have their own funds to purchase elsewhere if medicines are out of stock at Medical Stores Department. The similar availabilities of medicines observed in the public and non governmental organization sectors are due to the fact that both sectors follow the government medicine policy and procure most of their medicines from Medical Stores Department. Like the public sector, nongovernmental organization facilities were found to be stocking one generic equivalent per medicine surveyed, as evidenced by the lack of highest priced generic products found. The unavailability of highest priced generic products suggests that either the policy on generic prescription is adhered to in this sector as well or that their prices would be unaffordable to most Tanzanians and therefore having them in stock would create a risk of wastage. As in public sector health facilities, some nongovernmental organization health facilities were also practicing cost sharing schemes. Nongovernmental organization health facilities in some regions were found to charge flat rates for services. For example, at K S or Uhai Baptist faith based organization health centres in Mbeya region, it was found that outpatient children were paying TShs 2500 (US$ 1.68). On Assessment of the prices and availability of medicines for children in Tanzania -- Page 26

the other hand, inpatient children were paying TShs 8000 (US$ 5.39). These charges included medicine, food and other services. In some facilities it was observed that children were receiving free medicines, which were being paid for by their respective parentʹs/caregiverʹs employer (e.g. Tanzania Railway Authority in Mbeya region). 5.5 Intersectoral comparison of patient prices This survey of medicines prices in Tanzania showed that the prices of childrenʹs medicines vary depending on a number of factors such as the sector in which they are purchased, the type of procurement agent, and the distribution route. Large differences in the prices of the same generic substance were observed between the public, private and nongovernmental organization sectors, and in the private sector, between highest priced generics and their lowest priced generics equivalents. These findings describe a common trend that dominates in poor countries because of inefficient price regulatory mechanisms. As indicated earlier, prices in the public sector were consistently lower than in the private sector. While prices in both sectors were generally reasonable compared to international reference prices, large variations were observed across individual medicines with some costing several times more than international reference prices. This could be attributed to some pharmacies getting a discount by buying their products in bulk from suppliers and in turn selling medicines at a lower cost so as to increase turnover and profit. The findings in our survey also showed that medicine prices varied from facility to facility, especially in the private and nongovernmental organization sectors. 5.6 Affordability to patients While one issue is the price of medicines, another is whether people can afford them, regardless of how cheap or expensive they are. In this study, affordability was determined by comparing the cost of treatment with people s income. The monthly wage of the lowest paid unskilled government worker (TShs 135 000 or US$ 90.91) and the median medicine prices found at the sample facilities were used to calculate the number of days wages needed to purchase standard courses of treatment. The study found that the cost to the patient varied considerably between the public, the private and nongovernmental organization sectors. In general, a patient or parent/guardian had to work more to be able to purchase medicines from the private and nongovernmental organization sectors. Since the number of highest price generic products was limited, it was impossible to compare the affordability between highest price generic and lowest price generic products. In all the conditions it was more expensive to be treated in the private and nongovernmental organization sectors. For example, it was two times more expensive to treat septicemia with ceftriaxone in the private sector than in the public sector. However, consultation fees, diagnostic tests, and other costs were not included in these prices meaning that the total treatment cost would be considerably higher. The issue of medicine affordability is of paramount importance when access to medicines is considered. In Tanzania about 2.3 million people (13%) of the workforce are unemployed. The situation is worse in the rural areas and also amongst the youth. According to the Household Budget Survey of 2000 2001 the proportion of the Assessment of the prices and availability of medicines for children in Tanzania -- Page 27

population below national basic needs poverty line is 35.7% and these obviously are not covered by the national health insurance fund.(21) The majority of unemployed populations have monthly incomes of approximately TShs 40 000 (US$ 26.93), which is well below the measure used in calculating affordability in this study. For these populations, particularly for families in rural areas, affordability of medicines is likely to be much worse than the findings of this survey indicate and this may undermine the objectives of the National Medicine Policy. 6. CONCLUSIONS From this study of the availability and price of paediatric medicines in Tanzania, the following can be concluded: Availability of paediatric medicines: In the public sector procurement agency, the Medical Stores Department, only 27 of the 50 medicines surveyed were in stock at the time of the survey. In the public sector, the overall availability of childrenʹs medicines was low with mean availability of 32.0%, while the availability of medicines on the national essential medicines list was higher at 45.3%. Public health facilities are only stocking one generic product for each medicine. In the private sector, overall availability of lowest priced generic medicines in the basket was low (34.4%). Only 10 highest priced generic products were found suggesting that private facilities are generally only stocking one generic product for each medicine. Overall availability of childrenʹs medicines in the nongovernmental organization sector was low with mean availability of 32.1%. Availability of medicines on the national essential medicines list was higher at 43.2%. Nongovernmental organization health facilities are only stocking one generic product for each medicine. In the private sector medicines were, on average, more available in urban facilities (retail pharmacies) than in rural facilities (medical stores/accredited drug dispensing outlets, while in the public and nongovernmental organization sectors availability did not vary significantly between urban and rural areas. Anticonvulsants, opioid analgesics, zinc dispersible tablets, and certain antibiotics (e.g. ceftriaxone injection, gentamicin injection) showed consistently low availability across all three sectors. The categorization of salbutamol inhaler as a level D medicine in the national essential medicines list limits its availability at lower levels of care. Beclometasone inhaler also displays poor availability in all three sectors. Public sector procurement prices: Overall, paediatric medicines procurement prices were below international reference prices with a median MPR of 0.80, however the prices of certain injectables (epinephrine, gentamicin, phenobarbital) were substantially higher than international reference prices. Assessment of the prices and availability of medicines for children in Tanzania -- Page 28

All of the available paediatric medicines were on the national essential medicines list. Public sector facility prices: Overall, generic medicine prices were comparable to international reference prices with a median MPR of 0.96, however the prices of some medicines were more than double international reference prices. About 50% (6 of 12) of the lowest priced generic medicines had large price variations across individual facilities. Only 38.3% (18 of 50) of the facilities were either charging a flat rate or giving free medicines. Private sector facility prices: Highest priced generics cost, on average, 1.96 times the price of the equivalent lowest priced generics. For lowest priced generics, median prices were 2.22 times the international reference price, however one quarter of the medicines in the basket had median price ratios greater than 3.66. Overall, medicines prices showed little variability across private sector medicine outlets, however substantial inter facility variation was observed for epinephrine injection, vitamin K injection and prednisolone tablet. Nongovernmental organization facility prices: For lowest priced generics, median prices were 2.41 times the international reference price. More price variation was observed across nongovernmental organization facilities than across private sector facilities. Of the 48 facilities surveyed, only 14% (n=29) were charging patients a flat rate. Difference in prices between sectors: Public sector patient prices for the lowest priced generics were on average 19.4% higher than the public sector procurement prices. Private sector patient prices for lowest priced generics were one and a half times (154.9%) higher than public sector patient prices. Nongovernmental organization sector patient prices for lowest price generics were one and a half times (154.9 %) more than public sector patient prices. Nongovernmental organization sector prices were slightly more (9.8%) than the private sector prices. Assessment of the prices and availability of medicines for children in Tanzania -- Page 29

Affordability of medicines: s for both acute and chronic conditions are generally affordable for the lowest paid government worker. However, for the large sections of the population who earn less or are unemployed, purchasing treatment for their children may not be affordable. For malaria, 0.3 days wages are needed to purchase artemether + lumefantrine in the private sector while in the public and nongovernmental organization it is provided as a subsidized medicine. One month s treatment of asthma with a salbutamol inhaler costs the lowestpaid government worker 0.9 daysʹ wages if a lowest priced generic is used and 1.1 daysʹ wages if the originator is used. In the nongovernmental organization sector the lowest priced generic costs 0.7 daysʹ wages. 7. Recommendations The availability of essential medicines in Medical Stores Department should be 100%. More efforts should be made to include paediatric dosage forms on the national essential medicines. The pull system of public sector supply, using requisitions, should be strengthened. For example, the quantification of morbidity data should be enforced to provide the basis for calculation of medicine requirements in all health facilities. Cost sharing should be made uniform across health facilities. To avoid stock outs of childrenʹs formulations, local manufacturers should be encouraged to produce more varieties of essential medicine for children. The hospital therapeutic committees should be strengthened to improve rational use of medicines, particularly at the facility level. Assessment of the prices and availability of medicines for children in Tanzania -- Page 30

REFERENCES 1. Medicines for children, Fact sheet N 341, June 2010. Geneva, World Health Organization, 2010. 2. Health Sector Strategic Plan III, 2009 2015. United Republic of Tanzania, Ministry of Health and Social Welfare, 2009. 3. Tanzania Demographic and Health Survey 2009 2010. United Republic of Tanzania, 2010. 4. Mkakati wa Kukuza Uchumi na Kupunguza Umaskini Tanzania National Strategy for Growth and Reduction of Poverty II, 2010 2014. United Republic of Tanzania, 2010. 5. Economic Survey. United Republic of Tanzania, 2007. 6. Health Systems 20/20 Health Systems Database [online database] (http://www.healthsystems2020.org/). 7. National Drug Policy. United Republic of Tanzania, Ministry of Health and Social Welfare, 1991. 8. Standard Guidelines and the National Essential Medicines List for Mainland Tanzania, 3rd edition. United Republic of Tanzania, Ministry of Health and Social Welfare, 2007. 9. The World Medicines Situation. Geneva, World Health Organization, 2004. 10. Massele AY, Ofori Adjei D, Laing RO. A study of prescribing patterns with special reference to drug use indicators in Dar es Salaam Region, Tanzania. Tropical Doctor, 1993, 23:104 7. 11. Massele AY, Mwaluko GM. A study of prescribing patterns at different health care facilities in Dar es Salaam, Tanzania. East African Medical Journal, 1994, 71:314 6. 12. Massele AY, Nsimba SE. Comparison of drug utilisation in public and private primary health care clinics in Tanzania. East African Medical Journal, 1997, 74:420 2. 13. Massele AY, Nsimba SE, Rimoy G. Prescribing habits in church owned primary health care facilities in Dar es Salaam and other Tanzanian coast regions. East African Medical Journal, 2001, 78:510 4.. 14. Nsimba SE, Massele AY, Makonomalonja J. Assessing prescribing practice in church owned primary healthcare (PHC) institutions in Tanzania: a pilot study. Tropical Doctor, 2004, 34:236 8. 15. Le Grand A, Haaijer Ruskamp F, Hogerzeil H. Intervention research in rational use of drugs: a review. Health Policy and Planning, 1999, 14(2):89 102. 16. Measuring medicine prices, availability, affordability and price components, 2nd edition. Geneva, World Health Organization and Health Action International, 2008. 17. Globalization and Access to medicines: Perspectives on the WTO/TRIPS Agreement. Geneva, World Health Organization, 1999 (WHO/DAP/98.9, revised, 1999). 18. International Drug Price Indicator Guide, 2009 edition. Cambridge, Management Sciences for Health, 2009. 19. Continuity and Change: Implementing the third WHO Medicines strategy. Geneva, World Health Organization, 2010. 20. Medicine prices in Tanzania. Geneva, World Health Organization/Ministry of Health and Social Welfare, 2004. 21. Household Budget Survey 2000 2001. United Republic of Tanzania, National Bureau of Statistics, 2001. Assessment of the prices and availability of medicines for children in Tanzania -- Page 31

BIBILIOGRAPHY Bollinger L. HIV/AIDS and its Impact on Trade and Commerce. In: Forsythe S, State of the Art: AIDS and Economics, Policy Project, Futures Group, Washington, 2002:38 48. Conroy S. Unlicensed and off label drug use: issues and recommendations. Paediatric Drugs, 2002, 4(6):353 9. The Lancet. Rational use of medicines. Lancet, 2010, 375(9731):2052. Tanzania Service Provision Assessment Survey. United Republic of Tanzania, Ministry of Health and Social Welfare and National Bureau of Statistics, 2006. Baseline survey of the pharmaceutical sector in Tanzania 2002. Geneva, Ministry of Health and Social Welfare/World Health Organization, 2002. Press statement on accreditation of pharmacies. United Republic of Tanzania, National Health Insurance Fund/Ministry of Health and Social Welfare, 2 October 2003. Olcay M and Laing R. Pharmaceutical tariffs: what is their effect on prices, protection of local industry and revenue generation? Commission on Intellectual Property Rights, Innovation and Public Health, 2005. On the rational use of paediatric medicines. Papers Download Centre, 2007 (http://eng.hi138.com/?i136709 Posted:2007 8 6 16:58:00). Perez Casas C, Ford N, Herranz E. Pricing of Drugs and Donations: Options for sustainable equity pricing. Tropical Medicine and International Health, 2001, 6 (11):960 964. Perez Casas C, Ford N, Herranz E. Pharmaceuticals, and Parallel Trade. Competition Law Insight, 2003. Hospital, the phenomenon of irrational drug use and intervention. Medicine Papers Professional Medicine Papers, 2009 (http://eng.hi138.com/?i206887 Posted:2009 12 23 16:10:00). Sources and Prices of selected drugs and diagnostics for people living with HIV/AIDS. Geneva, World Health Organization in collaboration with UNICEF/UNAIDS/MSF, 2002 (WHO/EDM/PAR/2002.2). Assessment of the prices and availability of medicines for children in Tanzania -- Page 32

ANNEXES Annex 1: Timetable of survey Country: TANZANIA Activities Date Train area supervisors/data collectors 10 12 November 2010 Data Collection period 14 24 November 2010 Data analysis 25 November 2010 Preparation of draft report 1 20 December 2010 Assessment of the prices and availability of medicines for children in Tanzania -- Page 33

Annex 2: Medicines data collection form used for survey Facility Name: Address of facility: Urban vs Rural health facility: (tick) Urban Rural Address facility: of Urban vs Rural health facility: (tick) Urban Rural Region: Telephone Email: Facility No: Region: Telephone Email: Facility No: Fax: Type of health facility: (tick) Public Level of care Primary Secondary Tertiary Name and title of data collector: Date: (DD/MM/YYYY) / / / Mission Private Therapeutic committee available. (If yes. Ask to see last meeting s minutes) Name of manager of facility/disperser: Assessment of the prices and availability of medicines for children in Tanzania -- Page 34

INSTRUCTIONS 1. Facility information: Make sure that you fill all cells of the above table. If fax or e mail don t exist put N/A to indicate not available 2. Identifying products for price survey: Identify products with the exact strength and dosage form (if available) listed for each medicine that are physically available for sale or dispensing on the day of the data collection. Make sure that you do not mistakenly include products that are different strengths or different formulations (e.g. slow release tablet instead of regular tablet; or nasal spray instead of inhaler; or combination products which include another active ingredient) Look for products that have the recommended pack size. If products with the recommended pack size are not available then select the next larger pack size. Do not write down price information if the correct product is not physically available on the day of data collection in the health facility. Put No in ʺAvailable?ʺ column name to indicate not available Indicate whether the product is expired on the comment column. For ORS, comment whether is Low Osmolarity. 3. Recording data for price survey: You MUST write down the product name (e.g. trade name or brand name), the name of the manufacturer, actual pack size, and pack price found for the products with the highest and lowest unit price (i.e. price per capsule, tablet, millilitre, dose) For any given medicine, if there is only one product available, record data on this product in the row for the ʺlowest priceʺ product. Discounts: Record the discounted price in the ʺPack priceʺ column only when same discount is available for all patients If medicines are free to patients in public sector facilities then record availability and all product details and write ʺFʺ in the Pack Price Found cell 4. Calculating the unit price: Calculate the unit price after data collection, not at the facility as it will be too time consuming Divide the recorded pack price by the actual pack size found and write it down with up to four decimals (eg 0.1234) in the Unit Price cell. If the discount is applied for all patients, then calculate the unit price from the discounted pack price only. 5. Final steps: Please check that all data is correctly recorded and double check unit price calculations before sending the data collection forms to the Survey Manager Keep photocopies of completed data collection forms and send originals as soon as possible to: Prof Mary Justin Temu: maembekarau@yahoo.com, mtemu@muhas.ac.tz Send original data collection forms by post to: Prof Mary Justin Temu P.O. box 65013 Dar es Salaam If you have any questions please phone the survey manager at mobile 0784 320558 or landline2151244 or e mail shown above. Assessment of the prices and availability of medicines for children in Tanzania -- Page 35

Medicine name, dosage form, strength Recommended pack size Product of interest Available? ( Yes or No ) Product name (brand/ trade name) Manufacturer, country of manufacture Pack size found Pack price Discount for all patients Tick Yes No (%) Unit price (4 digits) Comments and observation i.e. if product is expired Albendazole chewable tablet 200 mg Albendazole suspension 100 mg/5 ml Amoxicillin suspension 125 mg/5 ml Amoxicillin /clavulanic acid suspension 125 mg + 31 mg/5 mi 2 20 ml 100 ml 100 ml Highest price /tab Lowest price /tab Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Lowest price /ml Highest price /ml Lowest price /ml Amoxicillin /clavulanic acid dispersible tablet 250 mg + 125 mg Artemether + lumefrantrine tablet 20 mg + 120 mg dispersible 21 6 Highest price /tab Lowest price /tab Highest price / tab Lowest price /tab Beclometasone Inhaler 100 mcg/dose Benzylpenicillin 1 MU = 600 mg/vial 1 inhaler (200 doses) 1 vial Highest price /dose Lowest price /dose Highest price /vial Lowest price /vial Assessment of the prices and availability of medicines for children in Tanzania -- Page 36

Medicine name, dosage form, strength Recommended pack size Product of interest Available? ( Yes or No ) Product name (brand/ trade name) Manufacturer, country of manufacture Pack size found Pack price Discount for all patients Tick Yes No (%) Unit price (4 digits) Comments and observation i.e. if product is expired Carbamazepine suspension 100 mg/5 ml Carbimazepine chewable tablet 100 mg 100 20 Highest price /ml Lowest price /ml Highest price /tab Lowest price /tab Canula 24 g 1 Highest price /unit Lowest price /unit Ceftriaxone injection 500 mg/vial Chloramphenicol injection 1 mg/vial Co trimoxazole tab, 20 mg trim + 100 mg suplhamethoxazole 1 vial 1 vial 15 Highest price /vial Lowest price /vial Highest price /vial Lowest price /vial Highest price /tab Lowest price /tab Co trimoxazole suspension 200 mg + 40 mg/5 ml) 100 ml Highest price /ml Lowest price /ml Diazepam rectal solution 2.5 mg/ml 0.5 ml Highest price /ml Lowest price /ml Diazepam 2 mg/2 ml Amp Highest price /ml Lowest price /ml Assessment of the prices and availability of medicines for children in Tanzania -- Page 37

Medicine name, dosage form, strength Recommended pack size Product of interest Available? ( Yes or No ) Product name (brand/ trade name) Manufacturer, country of manufacture Pack size found Pack price Discount for all patients Tick Yes No (%) Unit price (4 digits) Comments and observation i.e. if product is expired Digoxin 62.5 μg tablet 100 Highest price /tab Lowest price /tab Epinephrine (Adrenaline) 1 mg/ml Erythromycin oral suspension 125 mg/5 ml Ferrous Sulphate 30mg per 5 ml suspension Furosemide injection 20 mg/2 ml Gentamicin eye/ear drops 0.5% Gentamicin injection 10 mg/ml Hydroscortisone injection 100 mg 1 ml ampoule 100 ml 100 ml ampoule 10 ml 1 ampoule 1 vial Highest price /amp Lowest price /amp Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Highest price /amp Lowest price /amp Highest price /vial Lowest price /vial Isoniazid scored tablet 50 mg 56 Highest price /tab Assessment of the prices and availability of medicines for children in Tanzania -- Page 38

Medicine name, dosage form, strength Recommended pack size Product of interest Available? ( Yes or No ) Product name (brand/ trade name) Manufacturer, country of manufacture Pack size found Pack price Discount for all patients Tick Yes No (%) Unit price (4 digits) Comments and observation i.e. if product is expired Lamivudine 150 mg tablet (3TC) Morphine oral 10 mg/5 ml 100 100 ml Highest price /tab Lowest price /tab Highest price /ml Lowest price /ml Highest price /tab Morphine immediate 10 mg tablet Lowest price /tab MRDT Rapid diagnostic test for falciparum malaria pc Highest price /test Lowest price /test Nalidixic acid 250 mg 100 Highest price /tab Lowest price /tab Nevirapine syrup 50 mg/5 ml 100 ml Highest price /ml Lowest price /ml Normal Saline 0.9% Nystatin drops 100,000 IU/ml 500 ml 30 ml Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Assessment of the prices and availability of medicines for children in Tanzania -- Page 39

Medicine name, dosage form, strength Recommended pack size Product of interest Available? ( Yes or No ) Product name (brand/ trade name) Manufacturer, country of manufacture Pack size found Pack price Discount for all patients Tick Yes No (%) Unit price (4 digits) Comments and observation i.e. if product is expired ORS sachet to make 1 litre of solution Paracetamol suspension 120 mg/5 ml or 125 mg/5 ml 1 sachet 100 ml Highest price /packet Lowest price /packet Highest price /ml Lowest price /ml Low osmolarity? Yes Low osmolarity? Yes Phenobarbital 15 mg/5 ml 100 ml Highest price /ml Lowest price /ml Phenobarbitone injection 200 mg/ml 100 ml Highest price /ml Lowest price /mll Phenytoin suspension 25 or 30 mg/5 ml 500 ml Highest price /ml Lowest price /ml Phenytoin chewable tablet 50 mg 90 Highest price /tab Lowest price /tab Prednisolone 5 mg tablet 100 Highest price /tab Lowest price /tab Procaine penicillin injection 1mg/MIU Pyrazinamide (Z) 600 mg tablet vial 100 Highest price /vial Lowest price /vial Highest price /tab Lowest price /tab Assessment of the prices and availability of medicines for children in Tanzania -- Page 40

Medicine name, dosage form, strength Recommended pack size Product of interest Available? ( Yes or No ) Product name (brand/ trade name) Manufacturer, country of manufacture Pack size found Pack price Discount for all patients Tick Yes No (%) Unit price (4 digits) Comments and observation i.e. if product is expired Quinine 600 mg/2 ml injection Rifampicin suspension 100 mg/5 ml Sodium lactate comp (Ringers sol.) ampoule 100 ml 500ml Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Highest price /ml Lowest price /ml Salbutamol 2 mg tablet 100 Highest price /tab Lowest price /tab Salbutamol inhaler 100 mcg/dose 1 inhaler 200 doses Highest price /dose Lowest price /dose Lowest price /gram Vitamin K1 injection 10 mg/ ml Vitamin A 100,000 IU capsules (30 mg) 1 ampoule 100 Highest price /amp Lowest price /amp Highest price /cap Lowest price /cap Zinc 20 mg dispersible tablets 100 Highest price /tab Lowest price /tab Assessment of the prices and availability of medicines for children in Tanzania -- Page 41

Annex 3: List of facilities and outlets sampled GEOGRAPHICAL AREA: DAR ES SALAAM REGION Public Sector Private sector NGO sector Urban Rural Urban Rural Urban Rural Kwembe C.N. Pharmacy Mbweni Medics Aga Khan medical store Hospital Muhimbili National Hospital Mwananyamala Hospital Sinza Health Centre Amana Hospital Bweni : Kibamba Kinyerezi Salama Pharmacy Segerea Pharmacy Arafa Pharmacy G.P. Medicines medical store Mbweni Ubungo Medics Mbutu medics store Hindu Mandal Hospital Buruhani Health Centre Mikocheni mission Hospital Cardinary Rugambwa mission Hospital Kibangu mission Hospital Luguruni mission dispensary Mbweni mission Health Centre GEOGRAPHICAL AREA: SHINYANGA REGION Public Sector Private sector NGO sector Urban Rural Urban Rural Urban Rural Runguya Health Sun Palm Kitapondya Kalanfdoto AIC Centre Pharmacy Pharmacy (T) Hospital Shinyanga Regional Hospital Chamabuha Kambarage Mawaza Ushetu Shinyanga Pharmacy Jonson BLDB Pharmacy Isaka Libya Pharmacy Nyamonge Sokoni BLDB Lalago Health Centre Ng orongo DLDB Kadama Pharmacy Muhajirina Bakwata RC Ngokoro KKKT Igaririmu Health Centre Mpera health Centre Mbulu Magai Hospital GEOGRAPHICAL AREA: MANYARA REGION Public Sector Private sector NGO sector Urban Rural Urban Rural Urban Rural Bahati Town Council Hospital Magugu Health Centre Ikizu Pharmacy Gracious Medics Wazazi Dareda Hospital Nkaiti Health Centre Kiongozi Galapo Health Centre Dareda Kati Minjingu Eagle Pharmacy Timberland Medics Sabilo Waida Pharmacy Vumilia Medics Police Top In One Medics Kamba Medics Magereza Zaci Galapo Wazazi Galapo St. Imaculata Health Centre Assessment of the prices and availability of medicines for children in Tanzania -- Page 42

GEOGRAPHICAL AREA: MBEYA REGION Public Sector Private sector NGO sector Urban Rural Urban Rural Urban Rural Kiwanjampaka Health Centre Rungwe District Hospital Mina Pharmacy Tukuyu Medical Store Tazara Uyole Hospital Mbeya Referral Hospital Mbeya Regional Hospital Ruanda Health Center Kiwira Igawilo Health Centre Inyala Uhai Health Centre Msafiri Pharmacy Selya Day and Night Pharmacy Galatia Pharmacy Yubaha Medical Store Mwakifuna Medical Store Stephene Medical Store GM K S Hospital Uhai Bapt Iyunga Health Centre Mbalizi Hospital Igogwe Hospital Tukuyu (KKKT) Health Centre GEOGRAPHICAL AREA: MTWARA REGION Public Sector Private sector NGO sector Urban Rural Urban Rural Urban Rural Ligula Hospital Likombe Health Centre Bustand Pharmacy Twalibu ADDO Somo Ndanda Mission Mkomaindo Hospital Neawala Hospital Tandahimba Hospital Chisegu Nanguruwe Health Centre Mkuti Samira Pharmacy Chambila Pharmacy ABC Medics Salama ADDO Masasi Peak ADDO Laumbe Med Store ADDO SDA Mission Shangani Mission Bakwata Nanyamba Mission Health Centre Sajora Chikumba GEOGRAPHICAL AREA: TABORA REGION Public Sector Private sector NGO sector Urban Rural Urban Rural Urban Rural Manoleo Kavula Semeni Medical WMCA Ndala Mission Pharmacy Store Hospital Tabora (Kitete) Regional Hospital Isevya Town Council Clinic Malolo Magili : Mayombo Usoke Health Centre RM Medics Mmdawa Enterprise Pharmacy IDA Pharmacy Usoke Medical Store Umulinga Medical Store Huruma Medical Store SDA St Anne Health Centre St Philip Health Centre Kipalapala Mission Msele Medical Usoke Mission Assessment of the prices and availability of medicines for children in Tanzania -- Page 43

Annex 4: List of the paediatric medicines surveyed MEDICINE MEDICINE STRENGTH DOSAGE FORM TARGET PACK SIZE 1. Albendazole chewable tablet 200mg chewable tab 2 2. Albendazole suspension 100mg/5ml millilitre 10 3. Amoxicillin suspension 125mg/5ml millilitre 100 4. Amoxicillin+clavulanic acid suspension 125mg+31mg/5ml millilitre 100 5. Amoxicillin+clavulanic acid tab dispersible 250mg+125mg dispersible tab 21 6. Artemether+lumefantrine dispersible tab 20mg+120mg dispersible tab 6 7. Beclometasone inhaler 100mcg/dose dose 200 8. Benzylpenicillin injection 5MU (3g) vial 1 9. Carbamazepine suspension 100mg/5ml millilitre 100 10. Carbamazepine tab chewable 100mg chewable tab 20 11. Canula 24g unit 1 12. Ceftriaxone injection 250mg/vial vial 1 13. Chloramphenicol injection 1gm/vial vial 1 14. Co - trimoxazole tab 20mg+100mg tab 15 15. Co-trimoxazole suspension 8+40 mg/ml millilitre 100 16. Diazepam rectal solution 2.5mg/ml millilitre 0.5 17. Diazepam injection 2mg/2ml ampoule 1 18. Digoxin tab 62.5 µg tab 100 19. Epinephrine injection 1mg/ml ampoule 1 20. Erythromycin oral suspension 125mg/5ml millilitre 100 21. Ferrous sulphate suspension 30mg/5ml millilitre 100 22. Frusemide injection 20mg/2ml ampoule 1 23. Gentamycin eye/ear drops 0.3% millilitre 10 24. Gentamycin injection 10mg/ml ampoule 1 25. Hydrocortisone injecton 100mg vial 1 26. Isoniazid scored tab 50mg tab 56 27. Lamivudine (3TC) tab 150mg tab 60 28. Lamivudine suspension 50mg/5ml millilitre 100 29. Morphine oral suspension 10mg/5ml millilitre 100 30. Morphine tab immed release 10mg tab 31. MRDT (Rapid Diagnostic Test for Falciparum malaria) test 1 32. Nalidixic acid tab 250mg tab 100 33. Nevirapine syrup 50mg/5ml millilitre 100 34. Normal saline 0.9% millilitre 500 35. Nystatin drops 100,000IU/ml millilitre 30 36. Oral rehydration solution to make 1L sachet 1 37. Paracetamol suspension 24 or 25 mg/ml millilitre 100 38. Phenobarbital injection 200mg/ml millilitre 100 39. Phenytoin suspension 25or30mg/ml millilitre 500 40. Phenytoin tab chewable 50mg tab 90 41. Prednisolone tab 5mg tab 100 42. Pyrazinamide tab 400mg tab 100 43. Quinine injection 600mg/2ml millilitre 44. Rifampicin suspension 100mg/5ml millilitre 100 45. Ringers soln - sodium lactate comp. millilitre 500 46. Salbutamol tab 2mg tab 100 47. Salbutamol inhaler 100 mcg/dose dose 200 48. Vitamin K1 injection 10mg/ml ampoule 1 49. Vitamin A cap 50,000 IU (15mg) cap 100 50. Zinc dispersible tablet 20mg dispersible tab 100 Assessment of the prices and availability of medicines for children in Tanzania -- Page 44

Annex 5: Analysis summary sheets A5.1 Summary data from individual sectors A) Public sector procurement B) Public Health Facilities Sector Assessment of the prices and availability of medicines for children in Tanzania -- Page 45

C) Private sector pharmacies D) NGO sector facilities (other sector) Assessment of the prices and availability of medicines for children in Tanzania -- Page 46

A5.2 Comparisons of availability and price across sectors Assessment of the prices and availability of medicines for children in Tanzania -- Page 47

A5.3 Availability and price results by individual medicine Assessment of the prices and availability of medicines for children in Tanzania -- Page 48

Assessment of the prices and availability of medicines for children in Tanzania -- Page 49