Marc Twagirumukiza, MD, PhDClinical Pharmacology

Ghent UniversityGhent, Belgium

Prices of Antihypertensive Medicines in Sub-Saharan

Africa (SSA) and Alignment to World Health Organization’s Model List

Of Essential Medicines

Focus on SSA 47 countries (+ South Sudan since June 2011)

Total population (2010): 800 Million

−12.5% of the world population►1,2bn by 2025 −Wars, conflicts and instability

Economy :

−Only <10 % of global GDP (2008 est)−Farming for liverhood (75%) / Gender issues−GNI per capita: 858 US$

283 US$ in Burundi – 21 616 US$ in Seychelles – WB, 2008 est

Life expectancy at birth : 50.5 years (36 in Zambia – 73 in Mauritius )

Inequality in health spending by region (WHO, 2000)

EXTERNAL AID AS PERCENTAGE OF TOTAL HEALTH SPENDING (2000)

SSA: Health and wealth, who pays?

38%

34%

1%

23% 4%

Gouvernements (including donors)

Patients' (out-of-poket)

State health insurances

Private health insurance

Other sources

Source: WHO, 2004

Source : WHO 2005: «Preventing Chronic Diseases: A Vital Investment»

Global deaths by causes, 2005

Mortality worldwide: CVDs are responsible for more than 30% of all deaths (WHO, 2005)

• Morbidity worldwide: • 972 Mio hypertensive →will rise to 1.6 bn (2025)

• 65% in developing countries (including SSA).

• P.Kearney, The Lancet, 2005

HT7.1Mio

HT in SSA Prevalence, Gender and burden

From population studies, 1998-2008

2008 in SSA: 74,7 million

(38.3M; 36.4M) people with hypertension and prevalence of 16.2%

2025 in SSA: 125 million people with hypertension and a prevalence of 17.4%

Twagirumukiza M, J Hypertens. 2011 Jul;29(7):1243-52.

SSA (1)

England (2)

USA (3)

Canada (6)

0

10

20

30

40

50

60

70

15-24 25-34 35-44 45-54 55-64 >=65Age-ranges (in years)

Hypertension prevalence in Africa Vs Western countries

Twagirumukiza M, Journal of Hypertension 2007.

HT is a major Cardiovascular (CV) risk factor

Hypertension

coronary heart

disease

peripheral artery

disease

heart failure

Cerebro-vascular disease

We can consider hypertension as a disease but at the same time as a risk factor for other CVDs.

Stroke mortality rate worldwide

Number of cases reaching hospitals are in last stage of complications – dying at home.

Stroke worldwide : DALYs lostDisability Adjusted Life Years : The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.

Access-to-medicines worldwide Documented worldwide: 1/3 of world’s

population lacks regular access-to-essential medicines.

(Source: WHO/DAP 1998 ) Global response (1977): World Health

Organization Essential Medicines List (WHO/EML): a limited range of medicines selected to meet better availability, better use of financial resources, and in that way greater access to care. Many countries have developed their “National Essential Medicines Lists” (NEMLs) from WHO model.

Those NEMLs can play a role in standardization of the hypertension treatment in SSA.

Benin Burundi Cameroon Congo DRC Ivory Coast Kenya Mozambiq

ue Niger Rwanda Senegal Tanzania Uganda

Data on NEMLs and drug prices were collected from 65 public and 65 private pharmacies (from 13 SSA countries).

Access-to-medicinesMethods

Antihypertensive medicines on WHO/EML

Classes Drug (ATC name) Dosage

Duretics Hydrochlorothiazide 25mg

β-blockers Atenolol50mg 100mg

ACE inhibitors Enalapril2.5mg

Calcium Channel blockers Amlodipine

5mg

NEMLsAll investigated countries had a NEML, and all advocated drug classes were represented.

14-15th WHO/EML (2005, 2007)

Overview of the situation NEMLs in sampled countries

Data on National Essential Medicine Lists (NEMLs) and drug prices were collected from 13 SSA countries.

All surveyed countries had a NEML but 38% were not updated in the last 5 years.

Advocated drugs in SSA countries: % of NEMLs having advocated drugs on at least one of the WHO/EML 2002, 2003, 2005, 2007

HCTZ=Hydrochlorothiazide, ATEN=Atenolol, ENAL=Enalapril, CAPTO= Captopril, AMLO= Amlodipine, NIFE SL= Nifedipine sustained release.

HCTZ ATEN ENAL/CAPTO AMLO/NIFE SL0.00

50.00

100.00

53.8%61.5% 61.5%

46.2%

% o

f NEM

Ls

Non advocated drugs on NEMLs (Listed for HT Indications!)

Diuretics: Furosemide (10 NEMLs)

β-blockers: Propranolol (6 NEMLs), Labetalol, Carvedilol.

ACE inhibitors: Ramipril, Lisinopril.

CCBs: Nifedipine short acting (5 NEMLs), Verapamil, Diltiazem, Nicardipine.

Centrally acting drugs: Clonidine (5 NEMLs), Reserpine.

DDD prices adjusted to PPP per capita

MET AMLO ATE CAPTO ENA HCTZ NIFE

0

20

40

60

80

100

120

140

BeninBurundi

CameroonCongo

DRCIvory coast

KenyaMozambique

NigerRwanda

SenegalTanzania

Uganda

Enalapril

Income adjusted price

Tropical Medicine and International Health, 2010; 15:350-361.

METAMLO

ATECAPTO

HCTZNIFE

0

5

10

15

20

25

Benin

Burundi

Cameroon

Congo

DRC

Ivory coast

Kenya

Mozambique

Niger

Rwanda

Senegal

Tanzania

Uganda

• High prices :→Amlodipine→Burundi & DRC

DDD prices adjusted to PPP per capita

Tropical Medicine and International Health, 2010; 15:350-361.

Manufacturer’s Selling Price

Wholesaler margins

Retail margins

Import Tariffs and other feesInsurance+ Freight

Cost build up

Components of price build up along the chain

Prashant Yadav, India, 2008

Price Components: Multi-country comparisonHidden costs of medicines

Sources: Levison and Laing 2003, Governments files, MoH in every country

Items Kenya RwandaTanzani

a NigeriaManufacturer price 0 0  0 0Import tariff 0 % 7 % 10 % 5 %Port charges 8 % 5 % 1 % 0 %Clearance and freight 1 % 8 % 2 % 4 %

Pre-shipment inspection 2,75 %  - 1,20 % - Pharmacy board fee     2 %  -Importer's margins 30 % 25 % 9 % 22 %VAT -   -  - 18 %Central government tax  -  -  - 1 %State government tax -   - 2 % 4 %Wholesaler 10 % 11 % 0 % 3 %Retail 20 % 25 % 50 % 50 %

Total mark up 72 % 81 % 77 % 107 %

Discussions, remarks and study limitations: • The outlets surveyed were chosen in each

country from the capital city and data from distanced rural areas could change according to transport add-ons.

• The survey was limited to drugs on NEMLs which were on the WHO/EML between 2002 and 2007.

• The present study ignored the price data from informal channels, such as street vendors, which should interact with the prices in SSA countries.

Discussions, remarks and study limitations:

• Additionally, the present study is descriptive and not explanatory (no analysis of reasons of price disparities)

• The prices discussed are prices for monotherapy whereas this does not necessarily reflect the cost of the management of hypertension since a patient with established hypertension requires more than one antihypertensive drug.

• Apart from the price, the quality of medicines, not analysed here, is also of utmost importance in treatment. The major weakness of all medicines price comparisons is that they assume that all medicines on the market are of equal quality and therapeutic value.

Assumption model : Cost of hypertension treatment (estimates for SSA needs)

Amlo

dipi

ne 5

mg

Ateno

lol 1

00m

g

Ateno

lol 5

0mg

Capto

pril

25m

g

Enal

april

5m

g

HCTZ 2

5mg

Nifedi

pine

LP 2

0mg

AAS Ju

nior

Reser

pine

Praz

ocin

e

AMLO+HCTZ

+AAS

NIFE LP+

HCTZ+AAS

RES+HCTZ

+AAS

RES+HCTZ

+PRAZ+AAS

ENAL+

HCTZ+AAS

CAPT+HCTZ

+AAS0.00

1.00

2.00

3.00

4.00

5.00

6.00

Cost

per

year

for

SSA

(bn $

US)

Conclusions SSA sampled NEMLs are partially in compliance with

WHO/EML.

Some still have less effective (Furosemide short acting) or dangerous drugs (Nifedipine immediate release formulation)

Prices of drugs advised by WHO/EML largely differ between drugs and for each drug within and between countries.

Adding advocated drugs on country's NEMLs nearly always contributes to reduce prices.

In general, hydrochlorothiazide is the cheapest drug and should be the drug to be considered first.

Treatment strategies

J Hum Hypertens. 2011 Jan;25(1):47-56 www.nature.com/jhh

Prices of Antihypertensive Medicines in Sub-Saharan Africa (SSA) and Alignment to World Health Organization’s Model List Of Essential Medicines

Thanks for your attention

“Although the nature tries classifying people into richest and poorest, it is an ethical obligation for scholars and scientists to find how health care can reach everyone!”

Marc Twagirumukiza