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Senegal
1
Senegal
Assessment
Louis Teulieres
Senegal
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The purpose of this study is to:
• Determine the key elements of access to
medicines in Senegal
• Estimate the various roles of operators in the
pharmaceutical sector
• Identify factors on which it would be possible to act
to improve the situation
• Propose possible actions to be implemented to
improve access
Senegal
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Economic and Health/Social Context
• GDP per capita: USD $435 in 1999
• Heavy burden of debt limits the volume of public
financing assigned to social sectors.
• High incidence of poverty, more than 30% of
households
• Main diseases (public facility consultations):
malaria (33.2%), skin diseases (13%), diarrhea
(8.1%), ENT conditions (6.7%) and respiratory
diseases (6%)
• Attendance at public facilities is low (30% on
average), and there are strong regional disparities
Senegal
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Characteristics of the Pharmaceutical
Sector
• Most drugs on the market imported
• Local production by two pharmaceutical companies:
 most branded products under license
 some generics (branded or International Nonproprietary
Names [INN]) -- less than 5% of turnover
• Distribution of medicines undertaken by:
 private sector (85% of the market, 2,500 references):
three wholesalers and 532 retail pharmacies
 public sector: five regional warehouses, and at base,
health care centers with essential medicines under INN
(350 references) with full cost recovery from population
 illicit market supply
Senegal
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Price of Medicines
Retail prices of medicines are controlled by the
Administration. They are calculated (in the two licit
distribution channels) by applying ad valorem
margins to the purchase prices, leading to high
multipliers (1.86 for the private field and 1.80 for
the public field) and a retail price nearly twice as
large as the “before-tax French wholesale price”
(BTWP).
Senegal
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Price of Medicines (2)
Private Sector
Specialties
C.I.F. (%)
Local Transit (%)
Importateurs (%)
Whole sale margin return fee to
French wholesaler
Statistics
(UEMOA) Tax
(CDAO) Tax
Subtotal Wholesaler (%)
Retailers Margin
Subtotal Retailer
Multiplier
Part of BTWP in the Public Price
Public
Sector
Social
Hospital
Liste
10
1.5
18.3
3.5
10
1.5
9.9
3.5
10
1.5
22
3.5
0
0
20
1
1
0.5
29.8
40.7
40.7
1.86
53.8
1
1
0.5
21.4
9.9
9.9
1.35
74.1
1
1
0.5
33.5
56.3
56.3
2.13
46.9
1
1
0.5
20
50
50
1.8
55.5
Senegal
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Financing of Pharmaceutical
Expenditures
Sourcing
Private
Public
Other
Total
Households
Direct
Contributive
6
46.3
52.3
Public or
associative
financing
1.1
3.2
1
2.1
3.2
Total
7.1
49.5
1
57.6
Source: estimation du consultant à partir des données budgétaires, des données de la PNA et
de celles de la DPM.
Senegal
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Financing of Pharmaceutical
Expenditures (2)
Household
Indirect
5.6%
P ublic and
Associative
Financing
3.6%
Household
Direct
90.8%
Senegal
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Method
Access to medicine is defined as a combination of geographic
accessibility, the nature and the availability of the supply, the ability
to pay, together with more qualitative factors, such as the quality of
the prescription, quality of drugs, and quality of dispensation.
• Definition of Access:
 Environmental factors (geographic access, physical availability
and financial accessibility)
 Effectiveness factors that strengthen or attenuate the former
ones
• Access Measurement:
 A theoretical approach to elaborate measure indicators
 A practical approach using two surveys
Senegal
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Geographical Accessibility
• Median coverage: 1 pharmacy per 18,000
• One health post with essential drugs for 7,400
people
• 78% of the population lives within 5 km of a
facility with a “sustainable” stock of
pharmaceuticals
Senegal
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Geographical Accessibility (2)
Population Coverage Compared to Poverty
Zones
Population
Pharmacies
Ratio population
by pharmacy
Dakar
2 326 929
24,4%
306
57,6%
7,604
7 Towns > 100 000 Hab.
1 257 745
13,2%
89
16,8%
14,132
Rest of the country
5 941 974
62,4%
136
25,6%
43,691
100,0%
531
100,0%
17,941
Senegal
9 526 648
Senegal
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Availability
• Determined from list of 26 tracer essential drugs
• 80% availability in the private sector
• 64% availability in the public sector
• 41% of surveyed patients stated they could not
buy a whole prescription because of availability
problems
Senegal
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Availability (2)
Total
Region
Dakar
Classes
Public
26
Private
26
Public
26
Private
26
Public
26
Private
26
100%
From 80% to 99%
From 50% to 79%
From 25% to 49%
From 0% to 24%
0%
2
7
10
4
3
0
3
12
9
1
1
0
2
6
11
4
3
0
4
9
11
1
1
0
5
5
6
6
2
2
8
11
4
2
1
0
Median Availability
64%
80%
65%
78%
62%
84%
Number of Products
Source : SNIP National Survey
Senegal
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Financial Accessibility
50% of population spends less than $3 per year on
health. 5% of the population spends over $35 per year.
Quintiles Spending Food
1
2
3
4
5
2,020
4,791
7,434
11,670
34,706
1,364
3,098
4,599
6,046
10,212
Outside Health Health
food
Part Spending
656
66%
436
1,693
66%
1,124
2,835
66%
1,882
5,624
66%
3,734
24,494 66%
16,264
Senegal
Drug
32%
32%
32%
40%
50%
Accessibility
level
139
360
602
1,494
8,132
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Financial Accessibility (2)
Diseases
Fever (malaria)
diarrhoea
Skin
ARI
STI
Median cost
Median price
cheapest
Frequence
treatment
0.539
0.131
0.211
0.098
0.021
1.000
Public
207
282
343
452
403
274
Private Ecart
519 -60%
1,951 -86%
1,574 -78%
1,904 -76%
5,856 -93%
1,177 -77%
Quintile 1
139
Quintile 2
317
Public Private
1,5 3,7
2,0 14,0
2,5 11,3
3,3 13,7
2,9 42,1
2,0 8,5
Public Private
0,7 1,6
0,9 6,2
1,1 5,0
1,4 6,0
1,3 18,5
0,9 3,7
Quintile 3
602
Quintile 4
1,494
Quintile 5
8,132
Public Private Public Private Public Private
0,3
0,9 0,1 0,3 0,0 0.1
0,5
3,2 0,2 1,3 0,0 0.2
0,6
2,6 0,2 1,1 0,0 0.2
0,8
3,2 0,3 1,3 0,1 0.2
0,7
9,7 0,3 3,9 0,0 0.7
0,5
2,0 0,2 0,8 0,0 0.1
Senegal
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DS/Health Spending
•
National Survey Results:
 Median price for drug purchase is 1,000 Fcfa, higher than
theoretical accessibility for 60% of the population
 24% of patients at public facilities were given a second
prescription to be filled in a private pharmacy where median
cost is 2,661 Fcfa, for a total cost of 3,661 Fcfa, higher than
theoretical accessibility for 80%
•
Comparison of Drug Expenditure with Daily Spending (DS):
 In public facilities, cost of recent drug purchases is 1.4 times DS
(1,591 Fcfa). In private pharmacies, costs are 1.6 times DS
(4,735 Fcfa).
 Cost was higher than 1 DS in public facilities for 29% of cases,
and for 50% of cases in private pharmacies
 For 15% of patients at public facilities and 30% of those at
private pharmacies, purchasing costs were equal or superior to
3 DS
Senegal
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DS/Health Spending (2)
• DS of customers at public facilities:
 Between 3,401 Fcfa and 5,160 Fcfa
 Corresponds to food expenditures of the 2nd
and 3rd quintiles of households in the DMS
• DS of customers at private pharmacies:
 Between 5,918 Fcfa in 10,341 Fcfa
 Corresponds to 4th and 5th quintiles
Senegal
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DS/Health Spending (3)
• Two Lessons:
 The 20% poorest population (1st quintile) seem
to be excluded from the system
 A clear cut difference exists between the two
sets of populations
Senegal
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Quality of Products and Services
• Average number of lines on a prescription:
 2.8 in the public sector
 2.6 in the private sector
• Essential drugs on prescriptions:
 44% in the private sector (9% as INN, 91% as
brands)
 72% in the public sector (47% as INN)
• Irrational combination of two products of same
class:
 35% in the public sector
 26% in the private sector
Senegal
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Quality of Products and Services (2)
• 19% of public sector patients receive a second
prescription to be bought in a private pharmacy
• Substitution: in 52% of cases, for a more
expensive product (private sector)
• Dispensation: only 22% of patients know what the
drugs are for, while 40% know how long they
should be taken
Senegal
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Quality of Products and Services (3)
Prescription Understanding
Total Understanding
Partial Understanding
No Understanding
Health Post
Customers
Pharmacy
Customers
26.20%
70.00%
3.80%
28.30%
64.10%
7.60%
Source : Enquête nationale
Senegal
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Patients Behavior and Opinion
• 36% patients buy prescription drugs without a
prescription
• 35% patients use traditional medicines (37% with
no education, 30% primary education, 26%
secondary education)
• 26% use the illegal market (64% because drugs
are cheaper, 27% because prescription not
needed, 17% because of location)
• Satisfaction: 93% in the private sector, 82% in the
public sector
Senegal
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Conclusions
• Drug access in Senegal is low
• Price setting mechanisms, based on proportional
markups, end up greatly multiplying pre-tax
wholesale price
• In the public sector, unauthorized price increases
lead to prices sometimes as high as private sector
• Prescription and dispensation practices contribute
to the situation
Senegal
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Conclusions (2)
• Dispensation practices often not satisfactory in private
sector
• Behaviors can be attributed to several factors:
 Payment system: based on proportional markups
 Unchecked commercial promotion of
manufacturers: target private sector doctors and
prescribers in public sector facilities
• Markups and promotion largely responsible for partial
failure of essential drug policy based on generics
• Illicit Market Appeal: for a significant part of population,
role keeps growing, consequences on treatment
duration and observance
Senegal
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