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Prices of Medicines for the Management of Pain, Diabetes And Kirua et al. International Journal for Equity in Health (2020) 19:203 https://doi.org/10.1186/s12939-020-01319-9 RESEARCH Open Access Prices of medicines for the management of pain, diabetes and cardiovascular diseases in private pharmacies and the national health insurance in Tanzania Rashid Bakari Kirua1,2, Mary Justin Temu1 and Amani Thomas Mori1,3* Abstract Background: High price is a major challenge limiting access to essential medicines especially among the poorest families in developing countries. The study aims to compare the prices of medicines used in the management of pain, diabetes, and cardiovascular diseases in private pharmacies and the National Health Insurance Fund (NHIF) in Tanzania. Pharmacy prices were also compared with the prices of medicines surveyed nationally by WHO/HAI in 2012. Method: This cross-sectional study was conducted in Dar es Salaam, Morogoro, Dodoma, and Kilimanjaro regions from February to April 2015. Data were collected from 33 private pharmacies, NHIF and, the HAI database. The study used the WHO/HAI methodology. The analysis was done using non-parametric Kruskal-Wallis and post-hoc pair-wise comparison Dunn test, while a possible change in prices between our survey and 2012 WHO/HAI national survey data was tested using a Sign test in Stata version 16.1. Results: Twenty-eight essential medicines, of which 9 are used for management of pain, 7 for diabetes, and 12 for cardiovascular diseases were analyzed. There was a significant difference in the mean pharmacy prices of some medicines between the regions and between the pharmacies and NHIF reference prices. NHIF reference prices were higher than the pharmacy prices for 16 of the 28 medicines. There was a significant increase in the prices of 5 out of the 8 medicines that were also nationally surveyed by the WHO/HAI in 2012. Conclusion: The study found that medicine prices in private pharmacies vary a lot between the study regions, which raises equity concerns. Also, there was a significant difference between the pharmacy and the NHIF reimbursement prices, which may expose patients to fraudulent co-payments or hinder timely access to prescribed medicines. Therefore, effective price control policies and regulations for medicines are warranted in Tanzania. Keywords: Essential medicines, Prices, Reference prices, Private pharmacy, Tanzania * Correspondence: [email protected] 1Department of Pharmaceutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P.O. Box 65013, Dar es Salaam, Tanzania 3Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kirua et al. International Journal for Equity in Health (2020) 19:203 Page 2 of 9 Introduction The situation in Tanzania Over the past two decades, there has been a substantial Tanzania is an East African country with more than 45 epidemiological transition of diseases from communicable million people [19]. The health system, which is largely to non-communicable diseases (NCDs). It is estimated public-owned, is organized in a pyramidal structure in that NCDs kill more than 40 million people annually, which the primary health facilities are at the base and which is almost two-thirds of all deaths [1]. The Global the specialized and referral hospitals are at the apex. A Burden of Disease study ranked diabetes, low back pain, comprehensive network of primary healthcare facilities and cardiovascular diseases such as ischemic heart dis- i.e. dispensaries and health centers serve most of the eases and stroke higher in the top 25 causes of disability- population. Each facility offers pharmacy services, how- adjusted life years (DALYs) [2]. The burden of NCDs in ever, due to frequent stock-outs patients often buy medi- developing countries where it is estimated that 80% of the cines in the private pharmacies and Accredited Drug total deaths from NCDs takes place, has been rising rap- Dispensing Outlets (ADDO). The later are authorized to idly [3]. The reasons behind the rapid epidemiological stock a limited list of prescription-only-medicines and transition in developing countries have been likened to are mainly located in underserved rural areas where unhealthy lifestyles such as lack of physical activities, un- there are no pharmacies [20]. healthy diets, alcohol, and tobacco use [4–6]. In 1999, the Tanzanian government established the Unlike infectious diseases, NCDs such as diabetes and National Health Insurance Fund (NHIF), which by then cardiovascular diseases do not disable a person instantly, it was a compulsory health insurance scheme for serving but progress slowly and if not managed early and effect- central government employees only. However, since ively can lead to even more severe disabling effects in 2002 membership has been extended to include all pub- the long-term [7]. Health expenditures also increase dra- lic servants, private sector institutions, individuals, and matically with the increase in the number of chronic their legal dependents. NHIF also manages the Commu- conditions affecting the patient because of the complex- nity Health Fund, which mainly serves the rural popula- ity of care [8]. Thus, the long-term health costs required tions and informal sector. As of December 2019, the for the management of NCDs that often include lengthy number of beneficiaries was about 4.9 million people, and expensive treatments can quickly drain household equivalent to 9% of the total population [21]. resources particularly in low-income settings where out- Because of this rapid increase of the beneficiaries and of-pocket health payments are common [9]. Governments low availability of medicines in public health facilities, in low- and middle-income countries are increasingly the NHIF accredits private sector health facilities includ- implementing alternative financing strategies including ing pharmacies and ADDOs to provide medicines to its health insurance in an attempt to improve access to members. Medicine prices in private pharmacies and drug healthcare and to protect families from impoverishing shops are unregulated, hence prices tend to vary depend- health expenditures [10–12]. ing on buying price, operational cost, and profit margin In December 2012, the United Nations General As- desired unlike in public health facilities where prices are sembly adopted a resolution on universal health cover- relatively uniform because they get most of their medical age, which among other things urged countries to supplies from the Medical Store Department. Also, NHIF provide affordable and quality healthcare to all [13]. does not usually update its reimbursement rates fre- Today, access to essential medicines remains a major quently, which may take more than 3 years [22]. This challenge to a large proportion of poor sections of popu- means that the actual costs incurred by providers can be lations in developing countries, especially among those much higher than the reimbursement rates, creating suffering from NCDs. This problem is exacerbated by fraudulent co-payments that may limit timely access to the high prices of essential medicines, which hinder ac- prescribed medicines, and further exposing patients to cess to care [14]. Several cost-containment measures to catastrophic out-of-pocket health expenditures. Therefore, prevent further escalation of treatment costs have been The study aims to compare the prices of medicines used proposed by the WHO including; regulation of mark- in the management of pain, diabetes, and cardiovascular ups in the pharmaceutical supply chain, exemptions or diseases in private pharmacies and the National Health In- reduction of tax for essential medicines, use of reference surance Fund (NHIF) in Tanzania. It further compares pricing, promoting the use of generics, and the use of pharmacy prices with the prices of medicines surveyed na- health technology assessment to inform pricing and re- tionally by WHO/HAI in 2012. imbursement decisions [15]. Nevertheless, the lack of technical capacity, supporting policy frameworks, and Methodology relevant data have hampered the effective implementa- Study design and context tion of these cost-containment strategies in most devel- This was a cross-sectional study, which was conducted oping countries [16–18]. in four regions of Tanzania, namely Dar es Salaam, Kirua et al. International Journal for Equity in Health (2020) 19:203 Page 3 of 9 which is located in the coastal zone, Morogoro and pharmacies and 5 out of the 9 accredited pharmacies Dodoma in the central zone, and Kilimanjaro in the were surveyed. Kilimanjaro region has a population of northern zone (Fig. 1). The study used the World Health about 1.6 million people and is about 566 km from Dar Organization (WHO)/Health Action International (HAI) es Salaam. Kilimanjaro had about 23 private pharmacies methodology designed for measuring medicine prices, and 4 out of 6 accredited private pharmacies were availability, and affordability [23]. Data on the selected surveyed.
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