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3e. Child Health: Assessing Availability and Prices of Medicines for Children
Availability, Price, and Affordability of Key Essential Medicines for Children in a Resource-Limited Country
1Department of Pharmacology, Faculty of Medicine, University of Colombo, Sri Lanka; 22. Division of Medical Supplies and Technology, Ministry of Healthcare and Nutrition, Sri Lanka
Problem statement: WHO recommends that the first step in promoting access to essential medicines for children is to assess the current situation of their availability, prices, and affordability. This study reports such an assessment from a resource-limited country, which, to our knowledge, is the first reported survey, though similar surveys are ongoing in a few other countries.
Objective: To investigate the availability, price, and affordability of key essential medicines for children in Sri Lanka; we intend to use the survey results to plan strategies to ensure “better medicines for children” in Sri Lanka.
Design: The WHO and Health Action International Medicine Price methodology has been used for the first time for a country survey to evaluate whether the purpose of the essential medicines list has been achieved in Sri Lanka with regard to children.
Study setting, population, and sample: A representative sample of 40 public hospitals (OPD pharmacies) and 40 private and 8 State Pharmaceutical Corporation (Osusala) pharmacies were selected from the entire country by using a multistage, clustered approach (one province was excluded because of civil war).
Intervention: Survey medicines comprised 25 key essential medicines for children; availability data from the public sector; availability and price data from the private sector
Outcome measures: Mean percent availability of survey medicines in each outlet, percentage of outlets that had the survey medicines, median price ratio, and number of days the lowest paid unskilled government worker must work to buy standard drug therapy for common illnesses.
Results: Mean percent availability was 52% (SD = 14) in public hospitals, and 80% (SD = 11) in private pharmacies and 88% (SD = 9.5) in Osusala pharmacies. The wide gap in availability between the public and private sectors was observed mainly for liquid dosage forms of antiinfectives and inhaled dosage forms of antiasthmatics. Amoxicillin suspension was available in 45% of public hospitals compared to 100% of private and Osusala pharmacies. Availability of beclometasone and salbutamol inhalers was 50% and 37.5%, respectively, in public hospitals; 87.5% and 95%, respectively in private pharmacies; and 87.5% and 100%, respectively, in Osusala pharmacies. In the private sector, parents have to pay 0.05-3.75 times the international reference prices for lowest-priced generics and 0.23-20 times for originators. Mean percent difference in price between originator and lowest-priced generic products was 365% (range −21, 2343). Treatments for common diseases were unaffordable, especially for chronic diseases requiring liquid or inhaled dosage forms.
Conclusions: The purpose of the essential medicines list has not been achieved in Sri Lanka with regard to key essential medicines for children. In the public sector, the availability was poor, whereas in the private sector, the prices vary and are largely unaffordable. The wide gap between the prices of originator and lowest-priced generics calls for intervention.
Funding source: WHO/Sri Lanka, SEARO
Assessment of Availability, Price, and Affordability of Medicines for Children In Ghana
1Ministry of Health, Ghana; 2World Health Organisation
Problem statement: The goal of the Better Medicines for Children project funded by the Bill and Melinda Gates Foundation is to improve access to essential medicines for children by addressing issues of availability, safety, efficacy, and price. A study was undertaken to assess the current country situation concerning the availability and costs of medicines for children as part of project activities.
Objectives: To measure availability and patient price of a selection of paediatric medicines from public, private, and mission sectors in the country; to determine the affordability of medicines for children
Design: Descriptive cross-sectional study using quantitative methods
Setting: The country was stratified into three ecological and economic zones. Data were collected from public, private, and mission health facilities; private retail pharmacies; and licensed chemical shops. Data were also collected from the Central Medical Stores (CMS).
Study population: Convenience and random sampling was used to select urban and rural regions and the dispensing outlets in Greater Accra, Ashanti, and Upper West regions. Fifteen public sector, 30 private sector, and 4 mission sector medicine outlets were surveyed.
Intervention(s): The WHO/HAI method for conducting availability and price surveys was used. Data collectors visited facilities in September 2010 to collect data on availability and price. Data were also collected on government procurement prices. For each medicine, data were collected for the originator brand and lowest priced generic equivalent. Affordability was calculated using the number of day’s wages needed for the lowest paid government worker to procure standard treatments for diarrhea, moderate pneumonia, and uncomplicated malaria in children.
Outcome measure(s): Availability, price, and affordability of medicines for children
Results: (1) Mean availability of originator brand and generic medicines in the public sector was 2.7% and 19.3%, respectively. In the private and mission sectors, however, the mean availability of originator brand and generic medicines was 9.0% and 17.4%, respectively, for the private sector and 4.6% and 21.7%, respectively, for the mission sector. (2) Final patient prices for generic medicines in the public sector are 3.35 times their international reference prices. (3) The median price ratio of medicines procured at the CMS is 1.4. (4) Final patient prices for originator brands and lowest priced generics in the private sector are about 11.06 and 3.37 times their international reference prices, respectively. (5) In treating common conditions using standard regimen, the lowest paid government worker would need between 0.2 (diarrhea), 0.9 (moderate pneumonia), and 1.3 (malaria) days’ wages to purchase lowest priced generic medicines from the private sector.
Conclusions: Availability, price, and affordability of children’s medicines in Ghana should be improved to ensure equity in access to basic medical treatments.
Funding source(s): Bill and Melinda Gates Foundation
Incidence and Cost Estimate of Treating Paediatric Adverse Drug Reactions in Lagos, Nigeria
1Pharmacology Department, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria, Nigeria; 2Paediatrics Department, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria; 3Pharmacy Department, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
Problem statement: Adverse drug reactions (ADRs) may cause prolonged hospital admissions with a staggering cost of treatment. The burden of ADRs in children has never been evaluated in Nigeria.
Objectives: To determine the incidence of paediatric ADRs and the estimated cost of treatment over an 18-month period
Design: This is a prospective observational study of children admitted to the paediatric wards of LASUTH in Nigeria, between July 2006 and December 2007.
Setting: LASUTH, a tertiary health centre situated in the capital of Lagos State, is funded by the Lagos State Government. The available facilities and standard of care obtainable from this hospital is comparable to the international standard. Paediatric health care is partly free at LASUTH; the cost of treating paediatric inpatients is partly borne by the Lagos State Government and by the parents.
Study population: During the study period, a research team comprising a paediatric clinical pharmacologist, paediatricians, and two hospital pharmacists prospectively assessed all admissions to the paediatric wards to determine whether patients were admitted as a result of a suspected ADR or whether an ADR had occurred during admission.
Method: ADRs were defined in accordance with Edwards and Aronson (2000) and identified on the basis that they were well recognized as shown by their inclusion in the summary of product characteristics, the Nigerian National Drug Formulary and the paediatric British National Formulary, or in previously published case reports.
Outcome measure(s): Numbers of ADR cases, their severity, and the suspected medicines were recorded. Medical and nonmedical costs to the hospital and patient were estimated for each ADR. Cost estimates were performed from the perspectives of the hospital (government), service users (patients), and the society (sufferers of the total costs accrued to treating ADRs).
Results: 2,400 children were admitted during the study; 12 (0.6%) were admitted because of ADRs and 23 (1.2%) developed ADR(s) during admission. 40 ADRs (severe: 23 cases, moderate: 15 cases, and fatal: 2 cases) were suspected in 35 patients and involved 53 medicines. An average of 4.2 to 4.5 medicines was used per patient with ADRs. Self-medication contributed to 7 cases of admission because of ADRs. Antibiotics (50%) were the most suspected medicines. All but 7 of the ADRs were type A (dystonia due to amodiaquine, artesunate, or cefixime; hypothermia due to amodiaquine, artesunate, or cefixime; macular and morbiliform rash due to albendazole; anemia due to carbamazepine; angioneurotic edema due to amodiaquine; seizure due to cefixime; and transient loss of vision due to quinine) that were idiosyncratic. Cutaneous (17; 43%) was the most common manifestation and presented mostly as erythema multiforme rash (7) and pustular rash (4); 8 ADRs were judged to be avoidable (electrolyte disturbance and hyperglycemia due to prolonged use of prednisolone; erythema multiforme due to prolonged use of phenobarbitone; electrolyte disturbance and ileus due to prolonged use of frusemide; hemolysis due to the use of co-trimoxazole in a glucose-6-phosphatase dehydrogenase deficient patient; and red man syndrome due to rapid administration of intravenous vancomycin). Approximately 1.83 million naira (USD 15, 466:60) was expended to manage all the patients admitted due to ADRs.
Conclusions: Treating paediatric ADRs was substantially expensive. Paediatric drug use policy in Nigeria needs to be reviewed to discourage self-medication, polypharmacy prescribing, and sales of prescription medicines without prescription.
Funding source: Self-funded
Survey of the Availability and Prices of Children’s Medicine in Chhattisgarh State
State Health Resource Centre, Chhattisgarh,India, India
Problem statement: Children are therapeutic orphans, lacking appropriate clinical trials, licensed medicines, formulations, information, etc. In Chhattisgarh, only 33% of children with diarrhoea receive ORS and only 66% receive treatment for ARI. High child mortality, preventable with appropriate and timely use of essential medicines, which is highly priced and therefore, increasing out-of-pocket expenditures are a concern.
Objectives: To document the availability and price of key essential medicines for children in public and private health facilities in the state of Chhattisgarh
Design: A facility-based, cross-sectional study of the availability, price, affordability, and price components of selected children’s medicines was undertaken using a standardized methodology from WHO-Health Action International. The prices, including government procurement prices, and availability of 50 paediatric medicines were collected from a random sample of 75 public sector facilities, 60 retail pharmacies, and 25 other private sector outlets (private clinics, nursing homes, dispensing doctors, and health facilities run by nongovernmental organizations), totaling 160 dispensing sites . A price components survey was also conducted to identify the add-on costs in the supply chain that contribute to final patient prices.
Setting: The study covering both private and public sectors was conducted in 6 geographical sites (districts) in Chhattisgarh state, India.
Study population: A total of approximately 160 outlets were randomly sampled among 28 types of medical dispensing sites from October to November 2010.
Policy: Need of centralised procurement and logistics systems for children’s medicine
Outcome measure(s): For each medicine, data were collected on the highest-priced and lowest-priced product found at each facility. Medicine prices are expressed as median price ratio (MPR), which are ratios relative to the MSH international reference prices for 2009. Using the salary of the lowest-paid, unskilled government worker, affordability was calculated as the number of days’ wages needed to purchase medicines for standard treatments of common conditions.
Results: The average availability of lowest-priced paediatric medicines in the public sector and NGO/mission sectors was only 17%. In the public sector, more than half (29/50) of the study medicines were not available in any of the facilities surveyed. In retail pharmacies and other private, for-profit outlets, availability was higher at 46% and 35%, respectively, for lowest-price medicines and the availability of highest-price medicines was 14% and 7%, respectively. Overall, the public procurement agency is purchasing medicines with reasonable efficiency at prices that are just under international reference prices (MPR = 0.96). Patients in private pharmacies are paying 1.82 and 1.38 times the international reference price, on average, to purchase highest-priced and lowest-priced products whereas in private hospitals and nursing homes, it’s 2.59 times. The manufacturer’s selling price (MSP) and mark-ups for wholesalers and retailers are principal contributors to the final patient price. For originator brand and branded generic products, the total cumulative mark-up from MSP to final price ranged from 34% to 46%, whereas for unbranded generics, it ranged from 376% to 413%.
Conclusions: The average availability of children’s medicines was poor in all sectors, with high mark-up in pricing, emphasising the need for a centralised procurement and logistics system for EML for children in Chhattisgarh.
Funding source: WHO-New Delhi