The prices people pay for medicines in Zimbabwe

Vol. 55, Nos. 1/4 CONTENTS January/April 2009 ORIGINAL ARTICLES HIV status disclosure among people living with HTV/AIDS at FASO, Mutare, Zimbabwe........... RA Kangwende, J Chirenda, RF Mudyiradima.................. 1 Incidence of neonatal morbidity at Gondar Town, Ethiopia................................................................... T Teka, T Desta, A Isheak, S Demamu................................8 Pattern of cleft lip and palate in Dar-es- Salaam.... PMR Caneiro, ER Massawe.............................................. 10 The prices people pay for Medicines in Zimbabwe. P Gavaza, T Simoyi, B Makunike, CC Maponga.............. 14 REVIEW ARTICLE Medications for chronic pain a practical review..... J Mielke. NOTES AND NEWS Instructions to Authors. Central African Journal o f Medicine. The prices people pay for medicines in Zimbabwe *P GAVAZA, ***T SIMOYI, ***B MAKUNIKE, ****CC MAPONGA Abstract O bjectives: To collect, analyse and com pare prices o f m edicines in different sectors and parts o f the country and to com pare th em w ith the m edicine prices in o ther countries. D e sig n : A p rospective cross sectional study. S e ttin g : P harm acy outlets in Z im babw e co m prising 27 retail pharm acies, 23 disp en sin g doctors, eight public h o spital p harm acies and seven m unicipal clinics. M a in O u tc o m e M ea su re s: M edian price ratios, 25thp ercentiles a n d 75,hpercentiles. R e s u lts : Innovator brands in the private secto r w ere p ric e d 10 tim es the International R eferences P rices (IR P) and m ore than three tim es the p rice o f generic m edicines. D ispensing doctors w ere charging the h ig h est prices for m edicines and the pu b lic secto r h ad th e least prices. T he national pro cu rem en t agency, N atP harm , p ro cu red m edicines at p rices slightly b elo w th e M an ag em en t Sciences fo r H ealth (M S H ) prices. Prices o f m edicines in the pu b lic secto r w ere h ig h er th an av erage p rices fo r m edicines from seven o th er A frican countries. C o n c lu sio n : M edicine p rices in Z im b ab w e are high, a scenario th at m ay com prom ise affordability and accessibility to m edicines especially b y the poor. U rgent steps are n eed ed to red u ce the level an d effect o f the h ig h p rices on the population, esp ecially the poor. Cent A JrJ M ed2009;55(l/4) 14-19 Introduction People need drugs to maintain health and for relief from pain, suffering and ill health. But drugs have to be bought. They have to be bought in foreign currency, including a part of those produced locally. They are expensive and the price is going up every day.1In many developing countries, medicines are unaffordable to the majority o f people. The cost o f health care and particularly the cost o f prescription medicines presents major challenges to public expenditure policies.2 M edicine costs account for a large proportion o f households', insurers and governm ents' health spending in m any A frican countries, including Zimbabwe. It has been estimated that up to 50% o f the population in Africa and Asia are unable to obtain necessary medicines.3The price o f medicines is one of the most important obstacles to access. The cost of pharmaceuticals in the overall budgets o f insurers and governments continues to be targeted and often become controversial issues.4 Poverty, declining national economy, foreign currency shortages, low insurance coverage and the high HIV/AIDS disease *University o f Texas at Austin College o f Pharmacy, Pharmacy Practice and Administration Division Room PHR3.209, Austin, TX 78712-0127, USA **Ministry o f Health and Child Welfare Pharmacy Department Kaguvi Building, 4thFloor Causeway, Harare, Zimbabwe *** World Health Organization,Parirenyatwa Annex Mazowe Road, Harare, Zimbabwe ****School o f Pharmacy University o f Zimbabwe P O Box A 178, Avondale Harare, Zimbabwe 14 Correspondence to: Dr CC Maponga School o f Pharmacy University o f Zimbabwe P O Box A 178 Avondale, Harare E-mail: cmaponga(a).medsch. uz.ac.zw Cent Afr J Med 2009;55(l/4) burden have further compounded the problem o f access to affordable medicines by the population, especially the poor. The above factors have made it difficult for the Zimbabwe National Drug Policy to realize its goal o f having 90% or more o f essential drugs available in all public health facilities in the country. Public sector surveys conducted in Zimbabwe over the years show that none o f the levels o f health facilities in the country achieved the 90% overall drug availability target.5 The formulation o f well informed and appropriate pricing policies requires the availability o f reliable information on medicine prices. While Zimbabwe and many other developing countries have policies that affect medicine prices, lack o f accurate information on the actual price o f medicines paid by patients makes it difficult to assess how well the pricing policies are working. This study was conducted to analyse and compare the prices o f medicines in the different parts of the health sector in the country and to compare them with those in other African countries. Experimental. A prospective study was conducted using the WHO and Health Action International (HAI) methodology as stipulated in the manual “Medicine prices: a new approach to measurement”.6 The study was conducted as part o f the broader Zimbabwe Medicines Survey 20047 and was conducted concurrently with similar studies in seven other African countries during the last quarter o f 2004. The standardised W HO/HAI questionnaire (data collection form) was used to collect medicines prices information from a sample o f health institutions in the country. The first section included four questions covering the name o f health facility, name o f town or district, type of health facility, type of price (i.e., procurement or price the patient pays). The second section was the medicine price data collection form which was designed to collect data on the prices patients paid for medicines. The form had a listing of 42 medicines including 29 on the WHO/HAI standard list. The use of this standard list of medicines allowed for international comparison o f the study results. In addition to medicines in the core list, a supplementary list o f 13 medicines was added. In developing the supplementary list consideration was given to the burden o f disease, local production and availability of fixed dose combination products. The substances added were those widely used in the country and were taken from the Essential Drugs List o f Zimbabwe (EDLIZ).8To facilitate national and international comparison o f results, only medicines with Management Sciences for Health (MSH) reference prices were included in the final list (Table I) o f medicines surveyed. Table I: Core and supplementary medicines used. Medicine Name Medicine Strength Dosage Form Target Pack size Core List (Yes/No) Aciclovir Amitriptyline Amoxicillin caps/tab Amoxicillin suspension A rtesunate Atenolol B ed o m etaso n e inhaler Betam ethasone 1 % cream Captopril C arbam azepin e C eftriaxone injection Chloroquine Cim etidine Ciprofloxacin C o-trim oxazole suspension Cotrim oxazole tab D iazepam Diclofenac Doxycydine Erythromycin Fluconazole Fluoxetine Fluphenazine injection G libenclam ide Hydrochlorothiazide Ibuprofen Indinavir Indomethacin Losartan Metformin M etronidazole Miconazole oral gel Nevirapine Nifedipine Retard O m eprazole Phenytoin Prednisolone Ranitidine Salbutam ol inhaler Stavudine+Lam uvudine+N evirapine 2 0 0 mg 2 5 mg 2 5 0 mg 125 mg 100 mg 5 0 mg 0 .0 5 m g/dose 0.01 2 5 mg 2 0 0 mg 1 g/vial 150 mg base 4 0 0 mg 5 0 0 mg 8 + 4 0 mg/ml 8 0 + 4 0 0 mg 5m g 25 mg 1 0 0 mg 2 5 0 mg 2 0 0 mg 2 0 mg 2 5 m g/m l 5 mg 2 5 mg 2 0 0 mg 4 0 0 mg 2 5 mg 5 0 mg 5 0 0 mg 2 0 0 mg 2 % cream 2 0 0 mg 2 0 mg 2 0 mg 1 00 mg 5 mg 150 mg 0.1 m g/dose 40+150+200 5 0 0 + 2 5 mg 1 00 mg cap/tab cap/tab cap/tab millilitre cap/tab cap/tab dose gram cap/tab cap/tab gram tab tab cap/tab millilitre tab cap/tab c ap /tab cap/tab c ap /tab cap/tab cap/tab millilitre c ap /tab cap/tab cap/tab c ap /tab c ap /tab c ap /tab cap/tab tab gram cap/tab tab c ap /tab cap/tab tab c ap /tab dose cap/tab cap/tab cap/tab 25 100 21 100 20 60 yes yes yes no yes yes yes no yes yes yes no no yes yes no yes yes no no yes yes yes yes yes no yes no yes yes no no yes yes yes yes no yes yes no yes yes No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Sulfadoxine-pyrim etham ine Zidovudine Cent Afr J Med 2009;55( 1/4) 200 50 60 150 1 100 0 1 00 1 70 100 0 100 1 00 500 100 0 30 30 1 60 30 500 1 80 100 0 30 1 00 100 0 40 60 100 30 1 00 100 0 60 200 60 3 1 50 15 For each medicine, three products were monitored, where available, including: 1) The innovator brand: the product made by the innovator; 2) Most sold generic equivalent: comprised the generic product that is most sold in the country. This was obtained prior to the data collection through an initial (national) survey o f the major wholesalers, private retail pharmacies and public sector institutions in Zimbabwe; and 3) Low est price generic equivalent: the generic equivalent medicine with the least price. This was identified at each institution visited. The lowest price generic equivalent identified in each pharmacy did not need to be the same for all institutions but could vary from one institution to the other. For each medicine, data collectors ascertained if the medicine was available, and then recorded the pack size found and its price. This information was later used to calculate the unit price for each o f the medicines found. A pilot study was undertaken during a weeklong field practice. Data collection was completed in four weeks (September to October 2004). Price data was collected from public sector (provincial and central hospitals and municipal clinics) and private sector (private retail pharmacies and dispensing doctors) institutions. The study was conducted in five randomly selected provinces o f the 10 provinces in the country, namely H a ra re (in c lu d in g C h itu n g w iz a ), M a sv in g o , Bulawayo, M anicaland and M ashonaland West provinces. The study used the sampling method described in the WHO/HAI manual for selecting a representative num ber o f health facilities and pharmacies. All the central and provincial hospitals in the selected geographic areas were surveyed. Retail pharmacies and dispensing doctors were randomly selected using the most recent Medicines Control Authority o f Zimbabwe (MCAZ)9 lists. Municipal clinics were conveniently selected during data collection as no accurate lists were available before going to the field. A total o f 25 private retail pharmacies, eight public (central and provincial hospitals) sector health facilities, 25 dispensing doctors and seven municipal clinics were planned to participate in the study. The study also collected secondary information on the national pharmaceutical situation in the country and procurement prices (tender prices) from the national government procurement agency, NatPharm. Data were entered and analysed using a computerised W HO/HAI International Medicine Price Workbook, which is a special application for M icrosoft Excel. Summary measures o f the medicine prices found during the survey were expressed as ratios relative to the MSH 2003 price list which was selected as a standard set o f reference prices. The use o f an international reference price allowed for standardised international comparison. Comparisons were done in local currency. 16 The study also compared the national prices in Zimbabwe with prices in other countries. Prices in local currency were converted to US dollars for comparison. Findings on medicines prices in this study are expressed mostly as “median price ratios” or MPRs. The MPR is a ratio o f the local price, in US dollars, over an international reference price (also in US dollars). The reference price was used as an external standard for evaluating local prices. To obtain an MPR for a local medicine, the Excel Workbook calculated the median among all the prices gathered during the field survey for that medicine in a sector. This is the “typical” local price charged to patients in that sector. The Workbook converted this typical local price into US dollars, and then divided that amount by the reference price for the same medicine. The resulting MPR shows how many times higher or lower the local price is, compared to the external international standard price. Median price ratios for a particular drug or sector were calculated and reported only in cases where the drug was found in at least four institutions. Results All the targeted pharmacy institutions (i.e., 27 private retail pharmacies, 23 dispensing doctors eight public hospitals and seven municipal clinics) were surveyed in the study. The prices o f innovator brand products in the retail pharmacy sector were found to be 10 times the MSH international reference prices (IRP) (Table II). Dispensing doctors had the highest generic medicine prices which were over eight times the IRP and approximately twice the patient prices in the other three sectors surveyed. Generic medicine prices in the private retail sector were one third o f the prices for the innovator brands (Table II). Table II: M edicine prices across sectors. Sector Median Price Ratios Innovator Brand Most Sold Generic Lowest Price Generic Retail pharmacy 9.82 3.64 3.35 sector Public hospitals - Municipal clinics - 2.59 7.86 4.52 2.57 Dispensing doctors 4.05 0.91 0.99 Public procurement 7.86 prices Cent A fr J Med 2009;55(l/4) P y r im e th a m in e + s u l f a d o x in e , d ia z e p a m , indomethacin and chloroquine had very high prices. In the dispensing doctors sector, they were selling for at least 20 times the IRP. Prices o f a few medicines were below the IRP in both the private and dispensing doctors sectors (e.g., Lorsatan and Betamethasone 1% cream). Public sector hospitals sold medicines at prices 226% and 169% higher than the Natpharm procurement prices for the least priced generic (LPG) medicines respectively (Table III). Table III: Price ratios and summary ratios in the public sector. Most sold generic (MSG) equivalent Lowest price generic (LPG) Procurement Sector MPR (n=2) Public Sector MPR (n=8) No. Of medicines in both sectors Ratio private to public 0.94 3.06 10 325.5% 0.97 2.61 19 268.6% The prices charged for the MSG and LPG medicines in the private sector were 54% and 22% higher respectively than the prices in the public sector (Table IV). The public sector has lower patient prices than the private sector in general though Glibenclamide and Hydrochlorothiazide were cheaper in the private sector than in the public sector. Table IV: Medicines prices in the public and private sectors. Public Sector MPR (n=8) Private Sector MPR (n=27) No. of medicines in both sectors Ratio private to public Most sold generic equivalent 2.57 3.72 12 154.0% Lowest price generic equivalent 2.89 3.44 25 122.3% The prices charged for the least priced generic medicines in the dispensing doctors sector were 155% higher than the public sector medicine prices (Table V). Table V: Comparison o f medicine prices between dispensing doctors and public sectors. Most sold generic equivalent Lowest price generic equivalent Public Sector MPR (n-8) Disp. Doctors Sector MPR (n=23) No. of medicines in both sectors Ratio Disp. Doctors to public 3.06 3.17 13.28 8.09 10 24 433.2% 255.1% The Z im babw ean public procurem ent agency, NatPharm, on average procures medicines for 13 US cents more than the average prices from eight African Cent A frJ Med 2009;55(l/4) countries (including Zimbabwe). The public sector patient prices in Zimbabwe are, on average, 78 US cents more than the median prices in eight African 17 countries. The prices o f medicines in Zimbabwe are higher than prices charged in other African countries (Table VI). However, the prices o f medicines sold in the private sector were on average slightly less than the average, prices in the other African countries that participated in the study. Table VI: Comparisons o f medicine prices with prices in other African countries. Sector Zimbabwe MPRs Average prices in 8 African countries (25“'-75"' Percentile) Public procurement LPG Public sector patient LPG Private pharmacy patient LPG 0.99 0.86 (0.65-1.16) 2.89 2.11 (1.25-2.78) 3.44 3.56 (3.04-4.41) Discussion The study results confirm that prices o f medicines in Zimbabwe are high. Medicine prices were highest in the dispensing doctors sector. The finding that some generic products were being sold for over 20 times the IRP is disturbing and raises questions about the way medicines are priced in the country. This may be indicative of the arbitrary nature of the setting o f prices o f medicines in the country. There are large medicine price differences between the public, private retail pharmacies and dispensing doctors sectors with the public sector having relatively lower prices. The public sector hospitals charge lower prices to patients for the majority o f the medicines studied. In the private sector, even the cheapest generic medicines cost 22.3% more than the prices paid by patients in the public sector. Given the limited availability o f m edicines in the public sector institutions, many patients are forced to buy their medicines from the private sector institutions which are pricier. This is a common finding in poor countries with poorly regulated pharmaceutical sectors. The prices o f innovator brands in the private sector was very high vis-a-vis the prices o f generic equivalent medicines (a very high brand premium). The prices o f innovator brand products were, on average, three times the price o f generic medicines in the private sector. This finding supports the need for accelerated generic competition. Public procurement by NatPharm through the international competitive tender system allows the country to purchase medicines at relatively low prices on the international market compared to prices for the private sector. The support exchange rate offered to NatPharm by the government for procurement o f drugs has also contributed to the low procurement prices vis­ 18 a-vis the other sectors in the country. More competitive prices can be obtained through bulk purchases (pooled procurement). This can be achieved if Natpharm could be more involved in the supply and distribution of essential medicines for the private sector as well as the public sector, than is currently taking place at the moment. However, comparison o f Zimbabwe public procurement prices with other African countries revealed that the country, on average, pays more for drugs than other African countries. This situation cannot be allowed to continue. There were minor price differences between generic medicines (i.e. MSG and LPG medicines) in all the sectors surveyed. The minor differences between these types o f medicines may indicate the existence of generic competition which is a positive development. The availability o f more generic products on the market will help curb price increases. Routine price monitoring (i.e. quarterly price surveys) should be conducted in Zimbabwe, given that better information on price, prices differences and factors contributing to the final cost o f a medicine are essential if the country is to find ways o f making medicines more affordable.6 Our study had several potential limitations. First, the survey gives only a snapshot of the medicine price situation in the country and does not provide information on the trends o f these prices overtime. Second, the study used the official exchange rate o f the Zimbabwean dollar to the US dollar. At the time o f the study, the official exchange rate o f $5 616.16 to one US dollar was just 10% lower than the parallel market exchange rate which gives a more market related value o f the currency given the distortions in the valuing of the local currency. This may have had an effect of increasing the US dollar prices o f medicines in Zimbabwe. Given that it was applied across the board, this did not have an effect on internal comparisons. Third, the use o f MSH IRP in comparing retail prices was not comparing like with like. The MSH reference prices are the medians o f recent procurement or tender prices offered by not-for-profit suppliers to developing countries for multi-source products. The use o f IRP did not affect inter-country price comparisons and international comparisons as all the other countries used the same reference prices. Fourth, the study examined 42 mostly used medicines in the country. Analysing these medicines may have introduced bias because the most commonly used medicines may represent those with lower prices. However, the medications used in the study are similar to the most prescribed medications in Zimbabwe. Conclusion The prices paid by people for medicines in Zimbabwe are high. Concerted measures and steps are urgently Cent A frJ Med 2009;55(l/4) needed in order to improve access to and affordability of essential medicines for all. Acknowledgements The permission to undertake this survey was given by the Ministry o f Health and Child Welfare (MOH & CW). The study was financially supported by the E uropean U nion (H ealth) and W orld H ealth Organisation/Health Action International. World Health Organisation/Health Action International also provided technical support to the study. 4. 5. 6. References 1. 2. 3. Lauridsen E. Address on the national workshop on drug policy and management. Victoria falls, 5-15 April 1987, Zimbabwe. 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Harare: Ministry o f Health and Child Welfare. 2005. Ministry ofH ealth and Child Welfare. Essential drugs list o f Zimbabwe. 4th ed. Harare, 2004. Medicines Control Authority o f Zimbabwe. Listing o f approved licensed prem ises. Harare: Medicines Control Authority. 2004. This work is licensed under a Creative Commons Attribution - Noncommercial - NoDerivs 3.0 License. To view a copy of the license please see: http://creativecommons.org/licenses/by-nc-nd/3.0/ This is a download from the BLDS Digital Library on OpenDocs http://opendocs.ids.ac.uk/opendocs/ Institute o f Development Studies