MONITORING MEDICINE AVAILABILITY AND PRICES

IN UGANDA

By Denis Kibira

HEPS Uganda

Background

The Ministry of Health, in collaboration with the World Health Organization (WHO) and Health Action International Africa (HAI-Africa) represented by the Coalition for Health Promotion and Social Development (HEPS-Uganda), has since 2006 conducted medicines prices and availability monitoring in 3 sectors (public, mission, private) and four regions of the country.

Objective To monitor the ongoing interventions by the

Ministry of Health within the Health Sector Strategic Plan to increase access to essential medicines to all Ugandans.

The purpose of this activity is:• To understand to what extent medicine prices

contribute to problems of access to medicines in a country

• To Inform policymakers when selecting policy options to improve accessibility of medicines

• To monitor the progress of pharmaceutical policy implementation

• To evaluate the impact of policy or regulatory interventions

Specific objectives:• To Show trends in the availability of essential

medicines• To find out the prices (to consumers) of these

medicines• To assess the affordability of these medicines

METHODOLOGY

• The surveys are conducted using the standardized WHO/HAI Medicine Prices Monitoring Tool[1].

• Forty key (regularly prescribed and dispensed) medicines were selected for price and availability survey.

• The medicines, priced lowest to consumers are considered.

• The survey is carried out in the public, private and mission[2] facilities.

• In the public facilities sections that provide medicines free of charge to patients are chosen and in mission facilities the survey is only carried out in facilities where medicine prices can be disaggregated (i.e. where there are set prices for medicines).

• The data is collected from approx. 100 randomly sampled facilities

• [1] www.haiweb.org/medicineprices• [2] According to this survey, Private sector refers to Private for

Profit and Mission sector refers to Private Not for Profit

FINDINGS

33

57 5652

5963

50

58

74 7478

70

79

67

29

7872

67

7771

75

0

10

20

30

40

50

60

70

80

90

Oct-Dec 06 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jul-Sep 08 Oct-Dec 08 Jul-Sep 09

Period

Perc

enta

ge A

vaila

bilit

y

PUBLIC PRIVATE MISSION

Trends in availability of 40 key medicines across sectors 2006-2009

Since 2006 medicine availability across all sectors has been unpredictable with many fluctuations observed. The public sector has consistently lagged behind

Availability

FINDINGS

54

64

73

60 58 60 57

14

5956

4350

64

44

0

10

20

30

40

50

60

70

80

Oct-Dec 06 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jul-Sep 08 Oct-Dec 08 Jul-Sep 09

Period

Perc

enta

ge A

vaila

bilit

y

Urban Rural

Availability of 40 key medicines across Urban and Rural facilities in Public sector 2006-2009

Availability was consistently higher in urban compared to rural facilities

FINDINGS

81 85 81

9686

75

93

8174

81

64

83 83 87

100 96

8188 86

6370

0

20

40

60

80

100

120

Oct-Dec 06 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jul-Sep 08 Oct-Dec 08 Jul-Sep 09

Period

Per

cent

age

Ava

ilabi

lity

Artemether/Lumefantrine Quinnine Inj Pyrimethamine/Sulphadoxine

Trend in availability of key antimalarial medicines 2006-2009 in public sector

Availability of Artemether /Lumefantrine, the first line Antimalarial remained high in the public sector. Availability of the second line treatment for malaria of Quinine injection has risen by 23% since October- December 2007. However, Pyrimethamine/ Sulphadoxine used for prophylaxis has reduced by 30% since 2006.

FINDINGS

44

3741 40

28

4650

3026

33

4852

4641

22

3733

36

24 25

38

2226 24

21 21 19

33

22 24 2421

31

0

10

20

30

40

50

60

Oct-Dec 06 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jul-Sep 08 Oct-Dec 08 Jul-Sep 09

Period

Perc

enta

ge A

vaila

bilit

y

Nifedipine Glibenclamide Metformin Cimetidine Omeprazole

Availability of medicines for ulcer disease, diabetes and hypertension (with highly growing morbidity) has been poorly handled in public facilities

Trend in availability of 5 key medicines for chronic diseases 2006-2009 in public sector

FINDINGS

3022 20 24

13

2526 26 26 2428 29 31

85 8980

86

96

75

157 8

14 17 16

0

20

40

60

80

100

120

Oct-Dec 06 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jul-Sep 08 Oct-Dec 08 Jul-Sep 09

Period

Per

cent

age

Amoxycillin susp Cotrimoxazole susp ORS Metronidazole susp

Although availability of Oral Rehydration Salts used in management of diarrhoea has continued to be high, other Paediatric formulations continued to be stocked in less than 30 percent of public facilities. This shows that pneumonia and respiratory tract diseases common in children are not adequately catered for.

Trend in availability of 4 key paediatric medicines 2006-2009 in public sector

MEDICINE PRICES

PrivUrban/PrivRural

MisUrban/MisRural

PrivUrban/MisUrban

PrivRural/MisRural

No. of times more expensive 1.00 1.14 1.06 1.11

No. of Pairs Compared 24 31 29 26

Comparison of medicine median price ratios between and within private and mission sectors

•Prices charged to consumers for medicines in Private facilities were comparable across urban and rural facilities (ratio 1:1). In the Mission sector medicines in the urban facilities were 14% more expensive for consumers than in the rural facilities. •A comparison between the Private sector and the Mission sector showed that medicines were 6% more costly in private urban facilities and 11% more costly in private rural facilities.

FINDINGS

816.5

625 625 645.8

458.3

270.8333.3

500 500550

600650

700 700

300200

300 300200 200

330

0100200300400500600700800900

Oct-Dec 06 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jul-Sep 08 Oct-Dec 08 Jul-Sep 09

Period

Am

ount

per

uni

t (U

GX

)

Artemether/Lumefantrine Quinnine Inj Pyrimethamine/Sulphadoxine

Price trends of key antimalarials- Private Sector

The consumer price of Artemether/Lumefantrine (first line antimalarial) has dropped from UGX 816.5 per tablet in Oct-Dec 2006 to UGX 333.3 per tablet in July-September 2009.. Price of an ampoule of 600mg of Quinine injection (the second line antimalarial) increased from UGX 500 to UGX 700 per ampoule over the period.

AFFORDABILITY

0.7 0.7

1.5

11

0.5

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Private Mission

Sector

No

.of

day

s' w

ages

Amoxicillin susp Nifedipine 20mg Glibenclamide 5mg

Affordability relates to the number of days the lowest paid government worker would have to work to pay for one treatment course of an acute condition or one month’s treatment of a chronic condition

Affordability of treatment for diabetes, hypertension and pediatric acute RTI: Private Vs Mission

The daily wage of the lowest paid government worker is at UShs 3,000 (1.714 US$) as per the 2006/07 Government of Uganda salary structure It would require close to 3.2 days wages for treatment in the private and 2.2 days’ wages in mission sector.

CONCLUSION

• Studies conducted indicate that availability and prices of medicines in Uganda are still a major hindrance to access to essential medicines

• The situation is particularly confounded for the 85% of Ugandans living in rural areas

RECOMMENDATIONS

In order to make “free care” policies in the public effective, MoH should:

• Increase funding mechanisms for medicines e.g. thru NHIS

• Improve Procurement and Supply Management (PSM) capacities

• Increase transparency and accountability in PSM

• Explore the complementarities envisaged in the Public-Private Partnerships for Health Policy

• Implement pricing mechanisms for medicines in the private sector to increase affordability