A Report of a Survey on Medicine Prices and Availability in Uganda

A REPORT OF A SURVEY ON MEDICINE PRICES AND AVAILABILITY IN UGANDA

By

Medicines Transparency Alliance (MeTA)

JULY-SEPTEMBER, 2014

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ABBREVIATIONS AND ACRONYMS

CSO : civil society organization

DANIDA : Danish International Development Agency

DHO : District Health Officer

DFID : Department For International Development

EMHS : ESSENTIAL MEDICINES AND HEALTH SUPPLIES

HAI : HEALTH ACTION INTERNATIONAL

HEPS : Coalition for health promotion and social development

HSSP : health sector strategic plan

HSSIP : HEALTH SECTOR STRATEGIC INVESTMENT PLAN

MeTA : MEDICINES TRANSPARENCY ALLIANCE

MMP : MONITORING OF MEDICINES PRICES AND AVAILABILITY

MoH : MINISTRY OF HEALTH

MPR : MEDIAN PRICE RATIO

NDA : NATIONAL DRUG AUTHORITY

NGO : non-governmental organization

NMS : NATIONAL MEDICAL STORES

NPSSP : NATIONAL PHARMACEUTICAL SECTOR STRATEGIC PLAN

PFP : PRIVATE FOR PROFIT

PNFP : PRIVATE NOT FOR PROFIT (MISSION)

WHO : World Health organization

UGX : UGANDA SHILLINGS

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EXECUTIVE SUMMARY:

Limited access to medicines undermines the health systems’ objectives of equity, efficiency and health development[1]. Price is one of the most predominant barriers of access to essential medicines. Periodic monitoring of medicine prices is very important in determining if medicines are available and affordable to patients. In July 2014, MeTA Uganda carried out a survey in 4 geographical regions (Eastern, Central, Western, and Northern) in Uganda across three health sectors (Public, Private and PNFP/Mission) on price and availability of forty essential indicator medicines.

The survey employed a standardized methodology and analytical Microsoft Excel co-developed by WHO and HAI Africa. A total 119 facilities were visited by a team of data collectors comprising of Pharmacists/ Pharmacy Technicians and social scientists having a bias in public health practice. The survey was managed by a Survey Manager who is a Pharmacist.

Key findings from the survey included:

·  Overall availability of the selected essential medicines in the public sector was at 69%, private sector at 73% and mission sector at 79%, these exhibiting a marginal increment from the findings of the previous study (July-Sept.2013) by 1%, 8% and 5% respectively.

·  14 medicines in the Public sector, 19 medicines in the Private sector and 22 medicines in the Mission sector had availability of over 75%,

·  6 medicines in the Public sector, one medicine in the Private sector while no medicine in the Mission sector had less than 25% availability observed.

·  Similar to the findings of the previous survey of July-Sept 2013, urban facilities were generally observed to have a higher overall availability of the selected essential medicines than the rural facilities, with the highest variation noted in the private sector of 21% and the lowest noted in the public sector of 2% between the urban and rural facilities.

·  Artemether/Lumefantrine (A/L) 20/120mg tablets availability in the public sector was observed to be at 95% (an increment of 6% from the previous survey) followed by 93% (an increment of in availability by 18%) and 90% (a 1% increment from the previous survey) in the private and mission health facilities respectively.

·  The public sector was found to have the lowest availability of paediatric formulations among the three sectors (with 18%, 15%, 44% for Amoxicillin suspension, Co-trimoxazole suspension and Metronidazole suspension respectively) while the private sector exhibited the highest availability of paediatric formulations (at 88%, 78% and 59% respectively).

·  Medicines prices in the mission sector were found to be comparable across the urban and rural facilities (MPR 1:1).

·  Prices of medicines in the rural private facilities were 33% higher than those in the rural mission facilities while medicines prices in the urban private facilities were 23% more expensive than those in the urban mission facilities.

·  Generally, treatment courses containing medicines like Omeprazole, Ceftriaxone, Salbutamol inhaler, among others, used for management of chronic ailments like Asthma, Ulcers and depression, still remain unaffordable in both the mission and private sector facilities.

1.  INTRODUCTION

1.1  Introduction and background

Good quality affordable essential medicines and health supplies ought to be accessible to all who need them, and in adequate amounts. However, this has not always been the case in Uganda, with 72% of government health units have monthly stock outs of any of the indicator medicines which proves a big obstacle to universal access to quality health care (National Health Policy, 2009). A deficiency in the availability of medicines in healthcare centres poses a major problem to good quality health service delivery. Lack of access to life-saving and health supporting medicines to the population is a direct contradiction to the fundamental human right to health.

Communicable diseases account for 54% of illness in Uganda, with Malaria being the leading cause of morbidity, accounting for about half of the country’s morbidity, and its prevalence among children under the age of 5 years at 42% (HSSP III, 2010). Thus, there is need to ensure that treatment required for management of Malaria and other key communicable diseases is in adequate supply in healthcare facilities at all times. In addition, Non-communicable diseases in Uganda, just like in many other Sub-Saharan African countries, have been noted to pose an emerging burden to the population. Hence, there is need to ensure adequate availability of medicines to manage these conditions.

One of the major drivers of the cost of healthcare in low and middle income countries health systems are medicines (Wagner et al., 2014). The degree of access to essential medicines can be measured using a several indicators that yield data on medicines availability and their retail prices, in both public and private sectors, in combination with key policy indicators (Cameron, 2013). Difficulty in finding reliable information on medicine prices and availability stands in the way of governments in constructing sound medicine pricing policies or evaluation of their impact.

Few countries have publicly available medicines prices and information related to their use is often obstructed by country-specifics (WHO & HAI, 2008). Often, for poor individuals, price determines whether a patient obtains a full course of therapy, an incomplete course, or no medicines at all. In Uganda, the MOH, WHO, HAI Africa and its local partner HEPS-Uganda, through the Country Working Group (CWG), have since 2002 monitored medicines availability and prices. This has, over time, helped provide information on the status of availability of essential medicines in Uganda. It is hoped that through regular monitoring of medicines availability and affordability, data generated will assist in examining access challenges due to low availability and unaffordable prices.

Healthcare services in Uganda are provided by both the public and private sectors. All Government of Uganda (Public sector) hospitals are expected to provide medicines free of charge, but a significant proportion of medicines are paid for by patients who buy them directly from private pharmacies, often due to stock outs in the public health facilities (Breman et.al., 2007).

Most people in developing countries, who need medicines, have to pay for them out of their own pockets and the high prices for these drugs become a question of life and death (MSF Access Campaign, 2011). Low availability and unaffordable prices do pose an obstacle to essential medicines access in many countries. Costs of medicines are approximately 3‐5 times more expensive in the private sector facilities as compared to public sector procurement costs. The monitoring system generates reliable and regular information on prices, changes over time, and comparisons between the three sectors (public, private and mission) and four regions of the country. By providing information on availability of key medicines and their affordability, this survey is an important complement to the ongoing efforts to improve access to medicines for Ugandans especially the poor and vulnerable. Until recently there has been little information on what government or people paid for medicine. Despite several interventions by the Ministry of Health and NMS to improve supply of the essential medicines, access to the medicines still remains low. Data from the various surveys of the CWG have revealed that universal access to medicines has not been achieved and that medicines remain unaffordable for a significant part of the population. Hence, it’s important to routinely monitor medicines prices and also do cross-country comparisons, to track progress of the various interventions made, as well as indentify medicines access challenges that need to be addressed. The results of the study will guide decisions on generation of strategies to improve affordability and availability to the population of Uganda.

1.2  Objectives of the Survey

·  To determine the availability of medicines in the public, private and mission sectors

·  To compare the prices of medicines in private sector (PFP Vs. PNFP/mission sectors)

·  To assess the affordability of treating key indicator conditions by ordinary Ugandans

·  Inform policy formulation and dialogue on Medicines availability and Prices in Uganda.

2.  METHODOLOGY

2.1 Survey Design

The survey utilized mainly quantitative methods in the assessment availability and prices of medicines in the public, private and mission sectors. The survey was conducted using a standardized methodology developed by WHO and HAI[2], where the lowest-prices of the available medicines in the health facilities visited were collected and the respective medicine prices were compared with the international reference prices to obtain a median price ratio (MPR), a parameter used for comparison of the medicenes with other rates. Daily income of the lowest paid government employee was used to assess the affordability of the medicines.

2.2 Geographical areas

The survey was conducted in four regions of Uganda (Central, Eastern, Western, and Northern). The four regions were chosen as a realistic representation of the diversity in epidemiological and geographical characteristics of the country.

2.3 Sectors and facilities

The survey was conducted in three sectors: public, private (PFP) and Mission (NGO/PNFP). All three contribute a significant proportion of health services in the country. The standard WHO / HAI methodology recommends thirty outlets per sector for a survey to achieve enough data points for analysis.[3] The current survey targeted a total 119 facilities disaggregated proportionally spread out in each of the sectors.

2.4 Sampling strategy

One hundred and nineteen facilities were selected for the survey (see Table 1). In each region, the main regional referral hospitals (purposively selected), district hospitals, health centre IIIs and IVs were selected to represent the public health sector facilities. 5 licensed community pharmacies, 3 drug shops and 2 clinics located within 5 km of each of the selected public facilities were purposively selected to represent the private sector.

The NGO facilities with similar characteristics to public sector (e.g. mission hospitals of similar size and capacity to the regional, district and sub-district hospitals in the region) were purposively selected.

Urban and rural representation was taken into consideration during the selection of the facilities. Urban areas were considered to be towns with a population of more than 50,000 and rural areas to at least 10 km away from the urban centers.

Table 1: Distribution of the 119 health care facilities that were surveyed

Northern / Eastern / Western / Central / Total
Public Rural / 8 / 5 / 5 / 5 / 23 / 39
Public Urban / 2 / 4 / 5 / 5 / 16
Private Rural / 3 / 0 / 2 / 5 / 10 / 41
Private Urban / 7 / 9 / 9 / 6 / 31
Mission Rural / 7 / 5 / 7 / 4 / 23 / 39
Mission Urban / 4 / 4 / 3 / 5 / 16

2.5 Medicines surveyed

The selection of a basket of 40 essential medicines was based on the methodology’s core and supplementary lists. The list was approved by the Pharmacy Division of the Ministry of Health – Uganda.

2.6 Data collection, entry, analysis and management

The data collectors made visits to the respective health facility and proceeded to collect data, after getting authorization from the respective DHO and the Health co-coordinator/owner/in-charge for the facilities. For each medicine, data on the lowest priced product (brand) that was physically available on the day of the visit is collected. All the data collection forms were checked for completeness and accuracy. The survey manager carried out random verifications of prices and availability of the medicines was done by phone.

Data analysis was done using the customized WHO / HAI Excel workbook. Tables, graphs are generated for report.

Affordability was measured using a benchmark of one day’s wages of the lowest paid government worker and a given treatment regimen was considered not affordable if they were more than one days’ wages. The following disease conditions were used in the calculations to reflect the affordability of the respective treatments; Diabetes Mellitus, Hypertension, anxiety, Urinary Tract Infections (UTI for adults), Asthma, Acute Respiratory Infection (children and adults), Peptic Ulcers, arthritis, Depression and Malaria.

2.7 Limitations of the study

The study design being cross-sectional in nature yields data which may not depict consistency in the availability of the medicines in the health facilities throughout the year.

The list of medicines was not exhaustive and did not take into consideration the new policy adjustments by the MoH and NMS, though the agreed-on list served as proxy medicines used for managing the most common public health problems in Uganda. The study also did not explore medicines prices in dispensing clinics where the price of medicines cannot be disaggregated from total cost (lump sum cost) of treatment given to patients or where flat fees are charged.

In a nut shell, the study aimed at provision of substantive data to reflect the overall status of availability and affordability of essential medicines in Uganda, which can be used to inform Government and Development partners on the status quo regarding availability and affordability of essential medicines in the country.

3.  RESULTS AND DISCUSSION

This section highlights the results of the study focusing on the availability and prices of the key essential medicines across all the three sectors, as well as their affordability. It also includes comparisons in availability of the medicines for this survey, with the findings previous survey (July-2013).

1)  Availability