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AVAILABILITY, PRICE AND AFFORDABILITY OF
KEY ESSENTIAL MEDICINES FOR CHILDREN IN A
RESOURCE LIMITED COUNTRY
A NATIONAL SURVEY
Balasubramaniam R 1, Beneragama BVSH 2, Sri Ranganathan S 1
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Department of Pharmacology, Faculty of Medicine, University of Colombo, Sri Lanka
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
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Background
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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
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To investigate the availability, price and affordability of key
essential medicines for children in Sri Lanka
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Methods
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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 :
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Outcome measures:
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Mean percent availability
Percentage of outlets which had the
survey medicines
Median Price Ratio
Number of days a lowest paid
unskilled government worker must
work to buy standard drug therapy for
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common illnesses
PHs: Data on availability
PP & ROSP: Data on availability, price
of originator brand , and price of
lowest-priced generic
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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 solution
21.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)
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)
Public sector
Private sector
• 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
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Results – Price (PP + ROSP)
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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
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Results – Affordability
Bronchial Asthma
Epilepsy
• Salbutamol (100 µg/dose)
and beclometasone (100
µg /dose) one inhaler each
• One bottle (100 ml) of
carbamazepine syrup (100
mg/ 5 ml) =
• 1.5 - 2.17 days’ wages for
the LPUGW
• 2.2 days’ wages for the
LPUGW
• Beclometasone 100 µg bd
for 3 months =
• Carbamazepine 50 mg tds
for one month=
– 1 day wage for the LPUGW
– 5 days wage for the LPUGW
However, 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
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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 population
3. 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 nature
2. Selection of sectors, sample and medicines can be further improved
3. Corporation of administrators, policy makers and private sector is
very vital to conduct a National survey of this nature
4. This assessment survey is the first step: Further studies are required
before interventions and policy changes are recommended
Implications for implementing policies
Immediate actions
Long term 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
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
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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
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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?
References
1.
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Department of Census and Statistics Sri Lanka. Estimated mid year population by age and sex 20002010. Available from http://www.statistics.gov.lk. Accessed on 10th October 2011
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
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
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
Management Sciences for Health (MSH) International Drug Price Indicator Guide, 2008.Available
from http://erc.msh.org. Accessed 10th October 2011
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)
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
Robertson J, Forte G, Trapsida JM, Hill S. What essential medicines for children are on the shelf?
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Bulletin of the World Health Organisation. 2009 Mar;87(3):231-7
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