AVAILABILITY, PRICE AND AFFORDABILITY OF KEY ESSENTIAL MEDICINES FOR CHILDREN IN A RESOURCE LIMITED COUNTRY A NATIONAL SURVEY Balasubramaniam R 1, Beneragama.

AVAILABILITY, PRICE AND AFFORDABILITY OF KEY ESSENTIAL MEDICINES FOR CHILDREN IN A

RESOURCE LIMITED COUNTRYA NATIONAL SURVEY

Balasubramaniam R 1, Beneragama BVSH 2, Sri Ranganathan S 1

1. Department of Pharmacology, Faculty of Medicine, University of Colombo, Sri Lanka 2. Division of Medical Supplies and Technology, Ministry of Healthcare and Nutrition, Sri Lanka

Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18, 2011 1

2

Background• Every child has a right to access to essential medicines. • The 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

• Our study examined the physical access (availability) and economic access (affordability) to key essential medicines for children in Sri Lanka

Objectives• To investigate the availability, price and affordability of key

essential medicines for children in Sri Lanka

3

Methods • Survey Model: WHO and

Health Action International Medicine Price methodology

• Survey design: Cross sectional descriptive survey

• Survey setting: All Provinces of Sri Lanka except Northern Province (Civil war)

• Survey sectors: Public hospitals (PH), Private pharmacies (PP), Rajya Osusala pharmacies (ROSP)

• Survey areas (Sample Units): Provinces(N = 9 -1 = 8)

• Sampling technique: Multistage clustered sample

• Survey period: May-June 2009

• Survey sample: Representative sample of 40 PHs, 40 PPs and 8 ROSPs (N = 88)

• Data collected : 1. PHs: Data on availability 2. PP & ROSP: Data on availability, price

of originator brand , and price of lowest-priced generic

• Outcome measures: 1. Mean percent availability2. Percentage of outlets which had the

survey medicines3. Median Price Ratio4. Number of days a lowest paid

unskilled government worker must work to buy standard drug therapy for common illnesses

1. Amoxicillin oral liquid 125 mg/5 ml (100ml)

2. Amoxicillin 250 mg (capsule/tablet)3. Amoxicillin + clavulanic acid oral liquid

125 mg + 31.25 mg/5 ml (100 ml)4. Beclometasone – MDI Inhaler 100

microgram/dose (200 doses)5. Carbamazepine oral liquid 100 mg/5 ml

(100 ml)6. Ceftriaxone Injection 1 gram (vial)7. Chlorphenamine oral liquid 2 mg/5 ml

(100ml) 8. Clotrimazole Topical cream 1% (20g tube)9. Cloxacillin oral liquid 125 mg/5 ml

(100 ml) 10.Cotrimoxazole oral liquid 200 mg + 40

mg/5 ml (100 ml)11.Diazepam Injection 5 mg/ml

(2 ml ampoule) 12.DEC 50 mg (tablet)

13. Domperidone oral liquid 5 mg/5ml (10 ml)

14. Erythromycin oral liquid 125 mg/5 ml (100 ml)

15. Ferrous salt oral liquid 30 mg/ml (250 ml)

16. Ibuprofen oral liquid 100 mg/5ml (60 ml)17. Mebendazole Chewable tablet 100 mg

(6 tablets)18.Mebendazole oral liquid 100 mg/5 ml

(30 ml)19.Metronidazole 200 mg (tablet)20.ORS Packet to make 1 litre of solution21.Paracetamol oral liquid 120 mg/5 ml

(60 ml)22. Paracetamol 500 mg (tablet)23. Salbutamol –MDI Inhaler 100

microgram /dose (200 doses)24. Salbutamol Respiratory solution 0.5%

(15 ml)25. Vitamin C 100 mg (tablet)

5

Results – Availability • Mean per cent availability: – PH= 52% (range = 25-75, SD=14)– PP = 80% (range = 56-96, SD = 11)– ROSP - 88% (range76- 100, SD = 9.5)

• Wide gap in the availability between public and private sector– Oral liquid dosage forms of anti infectives, carbamazepine,

ferrous, domperidone, ibuprofen, paracetamol – Inhaled dosage forms of anti-asthmatics

• Availability in public sector as good as to that of private sector – Oral solid dosage forms of amoxicillin, metronidazole,

mebendazole (chewable), paracetamol, vitamin C, ORS, chlorphenamine syrup

Public sector

Private sector

6

Results – Price (PP + ROSP) • Lowest priced generics (LPG): 0.05-3.75 times IRP • Originators (OB): 0.23-20 times IRP • 75% of survey medicines: Prices of the LPG > IRP • Exception (25%) where Prices of LPG < IRP – Amoxicillin-clavulanic acid suspension– Diethylcarbamazine citrate– Mebendazole chewable tablet– Salbutamol MDI and respiratory solution

• 15 medicines were available as both OB and LPG – Mean percent difference in price between OB and LPG of these

medicines = 365% (range -21, 2343): – Price of OB < LPG only for ibuprofen syrup

7

Results – Affordability Bronchial Asthma

• Salbutamol (100 µg/dose) and beclometasone (100 µg /dose) one inhaler each• 1.5 - 2.17 days’ wages for

the LPUGW• Beclometasone 100 µg bd

for 3 months = – 1 day wage for the LPUGW

Epilepsy

• One bottle (100 ml) of carbamazepine syrup (100 mg/ 5 ml) =• 2.2 days’ wages for the

LPUGW• Carbamazepine 50 mg

tds for one month= – 5 days wage for the

LPUGWHowever, a fair amount of Sri Lankan population works in the unorganized sector with

an average daily salary much lower than the daily salary of the LPUGW

LPUGW = Lowest paid unskilled government worker {daily wage 400/= (3.5 USD)}

Key lessons learned from the results 1. The availability of key essential medicines for children in the public

sector was poor in Sri Lanka 2. In the private sector, though availability was good, the prices vary

and largely unaffordable especially to low income population3. A wide gap between the prices of OB and LPG was observed for

many medicines

Key lessons learned from the survey 1. WHO/HAI Medicine Price Methodology can be adapted to conduct

a National survey of this nature2. Selection of sectors, sample and medicines can be further improved3. Corporation of administrators, policy makers and private sector is

very vital to conduct a National survey of this nature4. This assessment survey is the first step: Further studies are required

before interventions and policy changes are recommended

9

Implications for implementing policies Immediate actions

1. Disseminating the results 2. Raising awareness: children

need “better medicines”3. Identifying key essential

medicines for children (KEMc) expected to be available in different levels

4. Advocating for their sustained availability

5. Making KEMc as “Priority” medicines

Long term actions

1. Further studies are required 2. Evidence obtained from

these studies – Interventions

– National policies

3. Conduction of regular assessment surveys – To study the impact of

policy changes and interventions

10

Future research agenda 1. Poor availability in the public sector: could be due to

shortcomings in the supply system or prescribing practices or in both– Further detailed studies are required to understand

these two factors and determine the shortcomings

2. Variability in prices and wide gap observed between the prices of the OB and LPG in the private sector – Further detailed studies are required on pricing and

price components of key essential medicines for children

Acknowledgments 1. WHO/Sri Lanka and South East Asian

Regional Office (SEARO) for funding (SE SRL DDE RB 08 17.1.1)

2. Dr K Weerasuriya (WHO) and Mr. Martin Auton (HAI) for guidance and support

3. Ministry of Health and SPC authorities for approving the survey

4. Provincial Health authorities and hospital administrators for granting permission to collect data

5. Pharmacists in the respective survey settings for providing the data, Drs S A C Senadeera and R Thanikaivasan for assisting in data entry

6. Ms Priyani Perera, Ms Inoka Gammune, Mr Supun Perera of the Department of Pharmacology, Faculty of Medicine, Colombo for secretarial assistance Where is my essential medicine?

12

References 1. Department of Census and Statistics Sri Lanka. Estimated mid year population by age and sex 2000-

2010. Available from http://www.statistics.gov.lk. Accessed on 10th October 20112. Ministry of Healthcare and Nutrition and Department of Pharmacology, Faculty of Medicine,

University of Colombo. National list of Essential Medicines, Sri Lanka, 4th revision. Ministry of Healthcare and Nutrition and Department of Pharmacology, Faculty of Medicine, University of Colombo; 2009

3. World Health Organization. The Selection of essential drugs. Report of the WHO Expert Committee. Technical Report Series No 615. Geneva: WHO; 1977

4. United Nations Development Group. Indicators for Monitoring the Millennium Development Goals. United Nations: New York, 2003

5. World Health Organization. Medicines: Medicines for children June 2010. Available from http://www.who.int/mediacentre/factsheets/fs341/en/index.html. accessed on 10th October 2011

6. Health Action International and World Health Organization. Medicine prices, availability, affordability and price components, 2008. Available from http://www.haiweb.org/medicineprices/. Accessed on 10th January 2009

7. Management Sciences for Health (MSH) International Drug Price Indicator Guide, 2008.Available from http://erc.msh.org. Accessed 10th October 2011

8. Central Bank of Sri Lanka. Restructuring of Public Service Salaries of the Government of Sri Lanka Based on Budget Proposals -2006, No 6/ 2006 (April, 25, 2006)

9. World Health Organization. The selection and use of essential medicines. Report of the WHO Expert Committee, March 2009 (including the 2nd Model List of Essential Medicines for Children). Geneva: WHO; 2010

10. Robertson J, Forte G, Trapsida JM, Hill S. What essential medicines for children are on the shelf? Bulletin of the World Health Organisation. 2009 Mar;87(3):231-7