No. 11: July-September 2013

MonitorMEDICINE P R I C E No. 11 July-September 2013

Uganda Country Working Group

Ministry of World Health HEPS Uganda HAI AFRICA Health organisation Health Action International

with support from MEDICINE P R I C E Monitor Uganda

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 HSSIP Health Sector Strategic and Investment Plan MeTA Medicines Transparency Alliance MoH Ministry of Health MPR Median Price Ratio NGO Non-governmental organization NPSSP National Pharmaceutical Sector Strategic Plan PFP Private-for-Profit (health facility) PNFP Private-not-for-profit (health facility) WHO World Health Organization

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EXECUTIVE SUMMARY

Price is the most predominant barrier to access to essential medicines.1 Periodic monitoring of medicines is very important in determining if medicines are available and affordable to patients.

In September 2013, MeTA Council of Uganda implemented a Medicine Availability and Price (MAP) survey of 40 essential indicator medicines. The survey was a quantitative process that used the traditional WHO/HAI methodology in 4 geographical regions (Eastern, Central, Western, and Northern) of Uganda across 3 health sectors (Public, Private and Mission) on price and availability.

In total 120 facilities (taking into consideration urban and rural representation) were visited by a team of data collectors comprised of pharmacists/ pharmacy technicians and social scientists having bias in public health practice. The survey was managed by a Survey Manager who is a pharmacist.

Key findings from the survey included: • The overall availability of the surveyed medicines was 68% in the public facilities, 65% in private and 74% in mission facilities. • A relatively bigger proportion of urban-based facilities had medicines available than rural-based facilities. At 30%, the difference was highest the private sector. • 89% of the public and mission facilities had Artemether/Lumefantrine 20/120mg tablets physically available on the day of the survey compared to 75% of the private facilities. • Medicines for the most common non-communicable diseases (diabetes and hypertension) were found available in less than 70% of the facilities across the three sectors. • The public facilities had very low availability of paediatric formulations: amoxicillin suspension (11%), cotrimoxazole syrup (16%) and metronidazole syrup (45%). • Medicine prices were comparable between urban and rural facilities in the private sector (MPR 1:1). 1 Ellen FM & Hoen T (2003): TRIPS, Pharmaceutical Patents and Access to Essential Medicines: Seattle, Doha and Beyond

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• Medicines were 12% more expensive in urban than in rural mission facilities (MPR 1:1). • Comparing mission and private sectors, there was no difference in the price of 25 of the 40 essential medicines surveyed. • In the private and mission sectors, medicines for chronic conditions like asthma, depression, diabetes, hypertension and ulcers cost more than a day’s wage for the lowest paid government worker in Uganda. However, the following conditions are affordable in both sectors by the lowest paid government worker: RTI (both adult and paediatric), anxiety, arthritis and pain/inflammation.

4 Table 3:No. Availability 11: of 40 essential July-September medicines across sectors Oct-Dec 2010 2013

1. INTRODUCTION AND BACKGROUND

1.1 Introduction The Constitution of the World Health Organisation (1946) recognises access to medicines as a major component of the right to health. Therefore, periodic monitoring of medicine is very important in determining if medicines are available and affordable at the different levels in the distribution chain. One way of addressing the price barrier to access to essential medicines is by improving information flow through multi-stakeholder approaches that pool together diverse expertise. In Uganda, Ministry of Health (MOH), WHO and HAI Africa and its local partner HEPS Uganda through the Country Working Group (CWG) have since 2002 monitored medicine availability and prices. Medicines Transparency Alliance (MeTA) Uganda prioritised this activity in its work plan and funds were provided by the IMS.

1.2 Background

Uganda is among the least developed countries of the world. A big percentage of the population still lives under a dollar a day. Its health statistics are among the worst in the world. An estimated 7% of the population is living with HIV, which has put an extra burden on the country’s already weak public health system.

It is estimated that only one third of the population has access to essential medicines. Price is one of the most predominant barriers to access to medicines. In developing countries, at a national level, the cost of medicines may account for up to 80% of non-salaried health expenditure, and at community level, the majority of people pay out-of-pocket for the medicines they consume. It is clear, therefore, that price is often a determining factor in whether the government can offer treatment to its population for a particular disease, or whether an individual receives a full treatment, an incomplete course, or no medicine at all. Until recently, there has been little information on what government or people paid for medicine.

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 section of the population. The results of these studies guide decisions on a strategy for improving affordability.

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The monitoring system generates regular information on price changes over time, and comparisons between the three sectors (public, private and mission) and four regions of the country. By informing consumers and procurement agencies about current prices and patterns of price changes, these series of surveys are an important complement to efforts to improve access to medicines for Ugandans, especially the poor and vulnerable.

1.3 Objectives of the survey

By gathering and analysing comprehensive data on the prices of selected medicines in the four representative regions of Uganda and across three sectors (Public, Private for profit and private not for profit/NGO/mission), the survey aimed at achieving the following objectives: • To determine the availability of selected medicines in the public, private and mission sectors; • To compare the prices of selected medicines between the private and mission sectors; • To determine the affordability of treating key indicator conditions to ordinary Ugandans; and • To inform policy interventions aimed at improving access to essential medicines in Uganda

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2. METHODOLOGY

2.1 Design

The survey was conducted using the standard methodology co-developed by WHO and HAI1. The survey used mainly quantitative methods to assess availability and prices of medicines in the public, private and mission sectors (See annex 2 for the survey tool).

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 30 outlets per sector for a survey to achieve enough data points for analysis.2 The current survey targeted a total 120 facilities disaggregated as follows: 40 outlets per sector (20 rural and 20 urban) and in each region 10 per sector (5 rural and 5 urban).

2.4 Sampling strategy

One hundred and twenty (120) facilities - 40 facilities per sector - were selected for the survey (see annex 1). In each region, the main regional referral (purposively selected), district hospitals and health centre IVs were selected to represent the public health sector facilities. Five 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.

1 www.haiweb.org/medicineprices 2 It is noted that a number of validation studies (in addition to the 9 pilot studies) were done during the original process of methodology development. The most important validation was on the sampling frame where it was found that sampling more regions, and those in areas greater than one days car travel from the capital, and in each area from more outlets a greater distance from the main produced the same results as using the standard sampling frame. The adequacy of collecting data on just the originator brand and lowest priced generic equivalent was also studied – again it was found there was no significant difference in the results. The volatility of MSH prices (used as an external bench-mark) have also been studied and little volatility has been found. A paper on validation has been published, and is cited as Madden JM, Meza E, Ewen M, Laing RO, Stephens P, Ross-Degnan D. Measuring medicine prices in Peru: validation of key aspects of WHO/HAI survey methodology. Rev PanamSaludPublica. 010;27 (4):291–9. 7 MEDICINE P R I C E Monitor Uganda

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.

The list of sites surveyed is attached (Annex 1).

Urban and rural representation was taken into consideration when selecting. 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 centres.

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 Ministry of Health – Uganda.

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Table 1: Medicines surveyed

No Medicine Strength Dosage form Category 1 Aciclor 200mg Tablet Antiviral 2 Albendazole 200mg Tablet Anthelmintic 3 Amitriptyline 25mg Tablet Antidepressant 4 Amoxicillin 250mg cap/tab Antibacterial 5 Amoxicillin 250mg/5ml Suspension Antibacterial 6 Artemether/Lumefantrine 20/120mg Tablet Antimalarial 7 Bendrofluazide 5mg Tablet Diuretic 8 Betamethasone 1% w/v cream/ointment Anti-inflammatory 9 Carbamazepine 200mg Tablet Antiepileptic 10 Ceftriaxone 1gm Powder for inj Antibacterial 11 Cimetidine 400mg Tablet Anti-ulcer 12 Ciprofloxacin 500mg Tablet Antibacterial 13 Co-trimoxazole 8/40 mg/ml Suspension Antibacterial 14 Co-trimoxazole 400+80 mg Tablet Antibacterial 15 Dextrose 5% Injection Parenteral 16 Diazepam 5mg Tablet Anxiolytic 17 Diclofenac 50mg Tablet Analgesic 18 Doxycycline 100mg Capsule Antibacterial 19 Erythromycin 250mg Tablet Antibacterial 20 Fluconazole 200mg tab /cap Antifungal 21 Furosemide 40mg Tablet Diuretic 22 Gentamycin 80mg/ml Injection Antibacterial 23 Glibenclamide 5mg Tablet Antidiabetic 24 Mebendazole 100mg Tablet Anthelmintic 25 Metformin 500mg Tablet Antidiabetic 26 Methyergometrine 200ug/ml Injection Oxyticic 27 Metronidazole 200mg/5ml Suspension Antibacterial 28 Metronidazole 200mg Tablet Antibacterial 29 Nifedipine retard 20mg Tablet Antihypertensive 30 Nystatin 100000iu Pessaries Antifungal 31 Omeprazole 20mg Capsule Antiulcer 32 Oral Rehydration Salt - Powder Antidiarrhoea (ORS) 33 Paracetamol 500mg Tablet Analgesic 34 Phenytoin 100mg Tablet Antiepileptic 35 Prednisolone 500mg Tablet Antiinflammatory 36 Pyrimethamine /sulfadoxide 25/500mg Tablet Antimalarial 37 Propranolol 40mg Tablet Antihypertensive 38 Quinine 300mg/5ml Injection Antimalarial 39 Salbutamol 0.1mg(100mcg)/dose Inhaler Antiasthmatic 40 Tetracycline 1% eye ointment Antibacterial

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2.6 Personnel

One pharmacist or pharmacy technician and one social scientist with bias in public health, from each of the 4 regions were trained on how to collect data. A pharmacist with bias in public health was recruited as the survey manager, took the responsibility of setting up and conducting the survey, supervising data collectors, analysing the data, and writing the report.

An Expert Advisory Group guided the survey process through supporting the survey manager in setting up and conducting the survey; providing feedback on the survey findings and earlier drafts of this report; informing recommendations on policy options; and promoting the survey and its findings.

Table 2: Advisory Group NAME TITLE, ORGANIZATION 1. Mr. Nazeem Mohamed Chief Executive Officer, Pharmaceutical Industries 2. JoanitaLwanyagaNamutebi Head Quality Assurance, Joint Medical Store 3.Ms. Rosette Mutambi Executive Director, HEPS Uganda 4. Ms. HellenByomire Head Drug Information, 5. Mr. MorriesSeru Principle Pharmacist, Ministry of Health 6. Mr. SowediMuyingo CEO, Medical Access Uganda Limited 7. Mr. Joseph Mwoga National Professional Officer, WHO Uganda Country Office 8. Opio Sam Secretary, Pharmaceutical Society of Uganda 9. Fred Kitutu Lecturer School of Pharmacy, University 10. Denis Kibira Coordinator, MeTA Uganda

2.7 Data Collection

Prior to data collection, all survey personnel participated in a training/briefing led by the survey manager. Data collectors were provided with introductory letters from Ministry of Health. At the district, data collectors introduced themselves and the purpose of the survey to the District Health Officer (DHO) before proceeding to collect data from the selected facilities.

At the facility, for each medicine, data on prices and availability of the lowest priced product that was physically available on the day of the visit were collected using a standard data collection form. The collected data was delivered to the survey manager at the coordinating office physically or by courier or post. Data collectors retained a copy of their data collection forms in case there was need for further verification. The HEPS Uganda Secretariat in Namirembe, Kampala acted as the central coordinating office to support the logistics for the survey.

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2.8 Data validation, entry, analysis and management

The survey manager checked all the data collection forms for completeness and accuracy. Questionable entries were validated by contacting either the data collectors or the health facility or both. Validation of the data collection was conducted in 10% of the sampled outlets. This was done by calling the outlets using telephones contacts given on the data collection forms.

Data analysis was done using a customised WHO/HAI Excel workbook. Tables, graphs were generated for the report. Availability was determined as a percentage of facilities having a particular medicine on the day of the survey. Median price ratios (MPR) were calculated to compare prices between mission and private facilities. The following conditions were used to gauge affordability of medicines: Diabetes, hypertension, asthma, acute respiratory infection (ARI), peptic ulcers and malaria. The earning of the government’s lowest paid worker was used as a benchmark for affordability assessment.

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3. RESULTS AND DISCUSSION

3.1 availability Table 3 and Figure 1 below show the overall availability of medicines across the three sectors and comparison between rural and urban facilities.

Table 3: Overall availability of medicines in the surveyed facilities Jul-Sep 2013 Sector No. Facilities surveyed Median Availability (%) Overall 38 68 Public Urban 19 68 Rural 19 66 Overall 40 65 Private Urban 20 85 Rural 20 55 Overall 35 74 Mission Urban 16 85 Rural 15 66

The overall availability of the surveyed medicines was highest in the mission facilities (74%), followed by public (68%)1 and lowest in private facilities (65%). Generally, urban facilities had the highest availability compared to the rural facilities across all sectors.

Figure 1: Availability in Urban versus Rural facilities, Jul-Sept. 2013

90 85 85 80 74 68 66 68 66 70 65 60 55 %) (

ty 50

ili Urban b

la 40

ai Rural

Av 30 Overall 20 10 0 Public PrivateMission Sector

1 Compare with an average availability of 87% for 6 tracer medicines Ministry of Health (2012) reports in the National Performance Report on Medicines Management

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There was a 2% difference in availability between urban and rural facilities in the public sector, 30% difference in the private sector and 19% in the mission sector. The big difference in availability between urban and rural facilities in the private sector can be attributed to the fact that drug shops and clinics are the most common drug outlets in the rural areas in Uganda and in urban areas pharmacies are the most predominant. According to NDA statute1, drug shops are licensed to stock only Class C drugs whereas pharmacies stock all classes of drugs, and this could have affected availability of some medicines. a) Overall availability of the 40 essential medicines across the three sectors, Jul–Sep 2013

Table 4 below compares overall availability of the 40 essential medicines surveyed across the public, private, and mission sectors. • In the public sector, 45% (18/40) of the medicines were available in more than 75% the facilities and 35% (14/40) were in less than 50% of the facilities • In the mission sector, 40% (16/40) of the medicines were found in more than 75% of the facilities surveyed, whereas 12.5% (5/40) were in less than 50%. • In the private sector, 25% (10/40) of the medicines were in more than 75% of the facilities, whereas 15% (6/40) were in less than 50% of facilities.

1 National Drug Policy and Authority Act 1993

13 MEDICINE P R I C E Monitor Uganda Table 4: Overall availability of 40 essential medicines across sector Medicine Overall availability (%) Public sector Private sector Mission Sector Aciclor tab 200mg 50 65 74 Albendazole tab 200mg 37 30 46 Amitriptyline tab 25mg 95 70 83 Amoxicillin cap/tab 250mg 84 85 91 Amoxicillin susp 250mg/5ml 11 75 74 Artemether/Lumefantrine tab 20/120mg 89 75 89 Bendrofluazide tab 5mg 71 53 69 Betamethasone cream/ointment 1%w/v 32 60 43 Carbamazepine tab 200mg 82 65 71 Ceftriaxone 1g pwder for inj'n 76 68 83 Cimetidine tab 400mg 8 38 34 Ciprofloxacin tab 500mg 82 83 94 Co-trimoxazolesusp 8/40 mg/ml 16 65 57 Co-trimoxazole tab 400+80 mg 89 80 86 Dextrose 5% inj 84 58 77 Diazepam tab 5mg 95 80 74 Diclofenac tab 50mg 58 95 83 Doxycycline cap/tab 100mg 76 70 100 Erythromycin tab 250mg 63 65 80 Fluconazole tab /cap 200mg 32 38 49 Furosemide tab 40mg 61 55 66 Gentamycin inj 80mg/ml 45 63 80 Glibenclamide tab 5mg 55 53 63 Mebendazole tab 100mg 76 88 77 Metformin tab 500mg 71 63 66 Methyergometrineinj 200ug/ml 45 20 51 Metronidazole susp 200mg/5ml 45 50 63 Metronidazole tab 200mg 92 93 97 Nifedipine retard tab 20mg 79 63 74 Nystatinpessaries 100000iu 13 68 63 Omeprazole cap 20mg 66 85 83 Oral Rehydration Salt (ORS) 89 80 89 Paracetamol tab 500mg 89 98 100 Phenytoin tab 100mg 76 35 57 Prednisolone tab 500mg 16 75 74 Pyrimethamine /sulfadoxide (SP) tab 25/500mg 79 63 71 Propranolol tab 40mg 39 65 69 Quinimeinj 300mg/5ml 45 63 74 Salbutamol inhaler 0.1mg(100mcg)/dose 11 43 37 Tetracycline eye ointment 1% 89 60 69

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b) a comparison of overall availability of selected anti-malarial medicines across the three sectors:

Figure 2 below compares the overall availability of artemether/lumefantrine 20/120mg and Sulfadoxine/Pyrimethamine used for treating uncomplicated malaria and prophylaxis of malaria during pregnancy respectively, across the three health sectors.

Figure 2: Comparison of overall availability of medicines for malaria across sectors

100 89 89 90 79 75 80 71 70 63 %)

( 60 ty

ili 50 Public b la

ai 40 Private Av 30 Mission 20 10 0 Artemether/Lumefantrine• Sulphadoxine/Pyrimethamine -malarial medicines

89% of the public and mission facilities had Artemether/Lumefantrine tablets 20/120mg in stock on the day of the visit compared to 75% of the private facilities.

Sulphadoxine/Pyrimethamine had the highest availability of 79% in the public facilities followed by mission (71%) and lowest in the private at 63%.

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c) a comparison of overall availability of selected anti-diabetic medicines across the three sectors

Figure 3 below compares the overall availability of Glibenclamide 5mg and Metformin 500mg used in management of diabetes, across the three health sectors

Figure 3: comparison of overall availability of medicines for diabetes across sectors

90 80 80 71 66 70 63 63 60 %) ( 50 45

ili ty Public b

la 40

ai Private

Av 30 Mission 20 10 0 Glibenclamide 5mg -

At least 60% of facilities in the public, private and mission sectors had Metformin 500mg in stock on the day of the survey. Glibenclamide 5mg was less available in the public sector (45%), but more available in the mission sector (80%).

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d) a comparison of overall availability of selected anti-hypertensive medicines across the three sectors

Figure 4 below compares the overall availability of Nifedipine 20mg and propranolol used in management of hypertension, across the three health sectors.

Fig. 4: comparison of overall availability of medicines for hypertension across sectors

90 79 80 74 69 65 70 63 60 %) (

ty 50 ili 39 Public b

la 40

ai Private

Av 30 Mission 20 10 0 Nifedipine 20mg Propranolol -hypertensive medicines

The public sector had the highest availability of Nifedipine 20mg (79%) and lowest availability of propranolol (39%) compared to other sectors.

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e) a comparison of overall availability of selected paediatric formulations across the three sectors

Figure 4 below compares the overall availability of selected medicines formulated for paediatric use across the three health sectors

Figure 5: comparison of overall availability of paediatric formulations across sectors

80 75 74

70 65 63 60 57 50 %) 50 45 ( ty

ili 40 Public b la

ai 30 Private Av 20 16 Mission 11 10

0 Amoxicillin susp Cotrimoxazole susp Metronidazole susp

The Public sector had the lowest availability of appropriate paediatric formulations: amoxicillin suspension 125mg/5ml in 11% of facilities, cotrimoxazole syrup 8/40mg in 16% and metronidazole syrup in 45% of public facilities.

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3.2 Medicine prices

Table 5: Comparison of medicine median price ratios between and within private and mission sectors. PrivUrb/PrivRural MisUrb/MisRural PrivUrb/MisUrb PrivRural/ MisRural No. of times more expensive 1.00 1.12 1.00 1.00 No. of Pairs Compared 37 40 40 37

As shown in table 5 above, the prices charged to consumers for medicines in the private facilities were comparable across urban and rural facilities (ratio 1:1). However, in the mission facilities medicines were 12% more expensive in the urban than rural facilities (ratio 1:1.12).

Medicine prices were comparable between urban private and mission facilities and in rural private and mission facilities (ratio 1:1).

Table 6 below shows the median consumer prices per unit of selected medicines in the private and mission facilities. There was no difference in price of 25 of the medicines between mission and private facilities. A marked 50% and above price difference between prices in the private and mission sectors were noted for Mebendazole 100mg, Diclofenac 50mg , carbamazepine 200mg, Albendazole 200mg, Artmetther/Lumefantrine 20/120mg and Prednisolone tablets.

More information on prices is in annex 2.

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Table 6: Median unit price of the 40 medicines in the private and mission facilities Median unit price (Ushs.) Medicine PRIVATE MISSION % price difference SECTOR SECTOR Aciclor tab 200mg 300.0 300.0 0.0 Albendazole tab 200mg 1000.0 500.0 50.0 Amitriptyline tab 25mg 100.0 100.0 0.0 Amoxicillin cap/tab 250mg 100.0 100.0 0.0 Amoxicillin susp 250mg/5ml 30.0 30.0 0.0 Artemether/Lumefantrine tab 20/120mg 250.0 125.0 50.0 Bendrofluazide tab 5mg 100.0 100.0 0.0 Betamethasone cream/ointment 1%w/v 200.0 166.7 16.7 Carbamazepine tab 200mg 100.0 150.0 50.0 Ceftriaxone 1g pwder for inj'n 3000.0 3250.0 8.3 Cimetidine tab 400mg 200.0 200.0 0.0 Ciprofloxacin tab 500mg 250.0 250.0 0.0 Co-trimoxazolesusp 8/40 mg/ml 30.0 30.0 0.0 Co-trimoxazole tab 400+80 mg 100.0 100.0 0.0 Dextrose 5% inj 2000.0 2000.0 0.0 Diazepam tab 5mg 100.0 100.0 0.0 Diclofenac tab 50mg 50.0 80.0 60.0 Doxycycline cap/tab 100mg 100.0 100.0 0.0 Erythromycin tab 250mg 200.0 200.0 0.0 Fluconazole tab /cap 200mg 1000.0 1000.0 0.0 Furosemide tab 40mg 100.0 100.0 0.0 Gentamycin inj 80mg/ml 800.0 800.0 0.0 Glibenclamide tab 5mg 100.0 100.0 0.0 Mebendazole tab 100mg 50.0 100.0 100.0 Metformin tab 500mg 200.0 150.0 25.0 Methyergometrineinj 200ug/ml 2000.0 1100.0 45.0 Metronidazole susp 200mg/5ml 27.5 25.0 9.1 Metronidazole tab 200mg 50.0 66.7 33.3 Nifedipine retard tab 20mg 200.0 200.0 0.0 Nystatinpessaries 100000iu 285.7 300.0 5.0 Omeprazole cap 20mg 200.0 250.0 25.0 Oral Rehydration Salt (ORS) 500.0 500.0 0.0 Paracetamol tab 500mg 50.0 50.0 0.0 Phenytoin tab 100mg 100.0 100.0 0.0 Prednisolone tab 500mg 100.0 50.0 50.0 Pyrimethamine /sulfadoxide (SP) tab 25/500mg 500.0 500.0 0.0 Propranolol tab 40mg 100.0 100.0 0.0 Quinimeinj 300mg/5ml 1000.0 1100.0 10.0 Salbutamol inhaler 0.1mg(100mcg)/dose 8000.0 8000.0 0.0 Tetracycline eye ointment 1% 571.4 500.0 12.5

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d) Affordability

Affordability was calculated as the number of days the lowest paid government worker would have to pay for one treatment course of an acute condition or one month’s treatment of a chronic condition. Treatments less than or equal to one days’ wages are considered affordable. The monthly earning of the lowest paid government worker is UShs. 222,976 (U8L) before tax, and after tax it is Ushs. 156,083. This gives daily wage of about 5200 (2.00 US$) as take home. Table 7 below shows the number of days it would take the lowest paid government worker to pay for treatment of the most common diseases in the private and mission sectors.

Table 7: affordability (Daily wage of lowest paid government worker is Ushs. 5200) Treatment # of MTP (Ushs.) Days' wages Condition Select Medicine duration units per Private Mission (in days) treatment Private Mission (MTP/5200) (MTP/5200) Artemether/ Lumefantrine tab Adult Malaria 20/120mg 3 24 6000 3000 1.2 0.6 Amoxicillin cap/tab 250mg 7 42 4200 4200 0.8 0.8 Ceftriaxone 1g pwder Adult RTI for inj'n 1 1 3000 3250 0.6 0.6 Ciprofloxacin tab 500mg 7 14 3500 3500 0.7 0.7 Anxiety Diazepam tab 5mg 7 7 700 700 0.1 0.1 Arthritis Diclofenac tab 50mg 30 60 3000 4800 0.6 0.9 Salbutamol inhaler Asthma 0.1mg/dose as need 200 8000 8000 1.5 1.5 Depression Amitriptyline tab 25mg 30 90 9000 9000 1.7 1.7 Diabetes Glibenclamide tab 5mg 30 60 6000 6000 1.2 1.2 Nifedipine retard tab Hypertension 20mg 30 30 6000 6000 1.2 1.2 Co-trimoxazolesusp Paediatric RTI 8/40 mg/ml 7 70 2100 2100 0.4 0.4 Pain/ Inflammation Paracetamol tab 500mg 3 18 900 900 0.2 0.2 Ulcer Omeprazole cap 20mg 30 30 6000 7500 1.2 1.4

In both the private and mission sectors medicines for treatment of chronic conditions like asthma, depression, diabetes, hypertension and ulcers cost more than a day’s wage.

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4. conclUSION • The overall availability of the surveyed medicines was 68% in the public facilities, 65% in private and 74% in mission facilities • More of urban based facilities had medicines available than rural, a big difference of 30% being in the private sector • 89% of the public and mission facilities had Artemether/Lumefantrine 20/120mg tablets physically available on the day of the survey compared to 75% of the private • Medicines for the most common non-communicable diseases (diabetes and hypertension) were found available in less than 70% of the facilities across the 3 sectors • The public facilities had a very low availability of paediatric formulations: amoxicillin suspension (11%), cotrimoxazole syrup (16%) and metronidazole syrup (45%) • Medicine prices were comparable between urban and rural facilities in the private sector (median price ratio). However, medicines were 12% more expensive in urban than rural mission facilities • There was no difference in price of 25 out of the 40 essential medicines surveyed between mission and private facilities • In the private and mission sector, medicines for chronic conditions like asthma, depression, diabetes, hypertension and ulcers cost more than a day’s wage for the lowest paid government worker in Uganda. However, the following conditions are affordable in both sectors by the lowest paid government worker: RTI (both adult &paediatric), anxiety, arthritis and pain/inflammation

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References • Uganda: Health Sector Strategic Investment Plan 2010/11-2014/15 • Madden JM, Meza E, Ewen M, Laing RO, Stephens P, Ross-Degnan D. Measuring medicine prices in Peru: validation of key aspects of WHO/HAI survey methodology. Rev PanamSaludPublica. 010;27 (4):291–9 • MeTA Uganda Work Plan, 2012 • Ministry of Health 2008b.Access to and use of medicines by Households in Uganda, Report. Kampala, Uganda. • Ministry of Health, 2002.Pharmaceutical Baseline Survey, Report. Kampala, Uganda. • Ministry of Health, 2008a.Pharmaceutical Situation Assessment, Report. Kampala, Uganda. • Ministry of Health, 2010. WHO, HAI (HEPS) Medicine Price Monitor Volume 1-8. Kampala, Uganda. • Ministry of Health.MoH., 2008.Access to and use of medicines by households in Uganda. Kampala: Ministry of Health.MoH. • World Health Organisation, 2006. Health Financing: A basic guide. WHO; Western Pacific Region. • www.haiweb.org/medicineprices

23 MEDICINE P R I C E Monitor Uganda rural (20) 2 clinics 3 Drug shops 2 clinics 3 Drug shops 2 clinics 3 Drug shops 2 clinics 3 Drug shops T E (40) A P R IV A ugust, 2013 urban (20) 1.Gilead pharmacy 2.Rana medical center 3.Sky pharmacy 1.Feliesta pharmacy Lira 2.Gulu independant hospital 3. Opios clinic Gulu 4.Kakanyero pharmacy Gulu 1.Frosa pharmacy Nakulabye 2.Genesis pharmacy 3.Bugolobi maternity 4.Case clinic 4.Kadic clinic 1..Mayanja memorial 2. Community 3.Multiple pharmacist 4.Muilticare pharcacy rural (20) 1.Walukuba HC 1.Walukuba 2. Buwenge HC jinja 3. Budadiri HC Mbale 4. Bubulo HC Mbale 5. Bududa hospital 1.Ogur HC 2.Amuc HC Lira 3. Dokolo HC 4. Lalogi HC Gulu 1.Kayunga hospital 2.Kawolo hospital 3.Mukono HC 4 4. Gombe hospital or any HC 4 1.Nakivule HC 4 2.Ishongorera HC 4 3.Nshengezi HC 4 4.Bwizibwera

PUBLI C (40) Pallisa urban (20) 1. Jinja Regional Ref hospital 2.Mbale regional Ref hospital 3. Iganga hospital 4.Kamuli Govt hospital 5. hospital 1.Gulu regional Ref hospital 2. Lira regional Ref hospital 3.Amaka hospital Gulu 1. hospistal 2. hospital 3.Entebbe grade B hospital 4. hospital 1.Mbarara Reg Hosp 2.Kitagata Hospital Bushenyi 3. 4.Kambuga Hospital Rukungiri Mayuge 1.Irapa church of God HU Kamuli 2.St Francis Buluba hospital 3. Kolonyi health centreMbale rural (20) 3.Nagalama hospital 1.Nkokonjeru hosptal 2.Mukono Hospital 3.Nagalama hospital 4.St.Stephens dispensary 5.Makonge community HC Mukono 1.Nyakibale Hospital Rukugiri 2.Kyamuhanga Hospital Bushenyi 3.Rushere hospital Mbarara 4.Nyakishenyi HC4 1.Amai hospital Lira 2.Opit HC 3.Aloi HC Lira Aliwang HC Lira 4. 5.Alanyi HC Lira vailability and Prices of Medicine in Uganda: List facilities – MISSION (40) Lira A 1. Kamuli mission Hospital 2.Islamic University HC Mbale 3.Ahmadiya HC Mbale Austin HC Mbale 4.St- urban (20) 1.St Mary’s Hospital 1.St Mary’s Lacor Gulu health unit 2.PAG 1. hospital 2.Rubaga hospital 3.Mengo hostal 4.Kisubi hospital 1.Ibanda Hospital 2.Ishaka Hospital 3.Ruharo hospital 4.Kisizi Hospital 3.Amuca dispensary Lira 4.Ngeeta hospital Lira Eastern Region RE GION Northern Central Western A nnex 1: Monitoring

24 No. 11: July-September 2013 (DD/MM/ A ugust 2013 0 in the Pack Price cell [email protected] F acility C ode: Date of data collection: YYYY) / pack size found (pack price/pack size) to get unit price and write it decimals (e.g 0.1234) in the Unit Price cell. down up to four pack size found (unit price x size) to get and write it in the pack size cell price from the discounted pack only. For products where pack price is given; divide the by by the price unit the multiply is given; price For products where unit If the discount is applied for all patients, then calculate unit If medicines are free to patients like in the public sector facilities, record all product details and write Please check that all data is correctly recorded and double unit price calculations before sending the data collection forms to Survey Manager Send completed data collection forms by courier or hand deliver Box 2426, Kampala, as soon possible to: HEPS-Uganda, P.O. Balintuma Road, Mengo Calculating the unit or pack price: the unit or Calculating F inal steps: • • • • • • 4. 5. If you have any questions please phone the survey manager (GildoOkure) at +256782-959336 or e-mail to F acility E mail: Put ferent not only when ddress of facility : A ddress F acility ax: Data collector Name : Mobile: E -mail: If fax or e-mail don’t If fax or e-mail don’t vailability of Medicines in Uganda: Data C ollection F orm – A the lowest price Mission  Public Mission theexact strength and dosage form for each theexact strength (Tick): Record discount as % and the discounted price MUST write down the product name (that is trade or brand MUST exist put “N/A” to indicate not available medicine listed that are physically available for sale or dispensing on the day of the data collection Make sure that you do not mistakenly include products are of dif strengths or formulations (e.g. slow release tablet instead of regular tablet; or nasal spray instead of inhaler; combination products which include another active ingredient) Do not write down price information if the correct product is physically available in the health facility on day of data collection. “N/A” under product name to indicate not available Discounts: all patients same discount is available for Make sure that you fill all cells of the above table. Identify products with You actual pack size and name), the name and country of manufacturer, pack price found for the product with Facility information: products for price monitoring: Identifying monitoring: data for price Recording • • • • • • F acility Name:  Private R egion: District: :  Urban R ural Setting (Tick) acility Telephone: F acility of health facility Type A nnex 2: Monitoring Prices and INST R U C TIONS 1. 2. 3.

25 MEDICINE P R I C E Monitor Uganda omments and and omments observations C pack price Discounted Discounted for all? for Discount Yes  % Yes  %  %  %  %  %  %  %  %  %  %  %  % /ml /tab /tab /tab /tab /tab /tab /tab /tab /cap /vial /gram digits) Unit price (4 (4 price Unit Pack price found Pack size country of of country manufacture Manufacturer, Manufacturer, name) (brand / trade trade / (brand Product name Product es” or “N/ A ”) vailable? (“ Y A of interest Product Product Lowest priced Lowest price Lowest priced Lowest priced Lowest priced Lowest priced Lowest priced Lowest priced Lowest priced Lowest price Lowest priced Lowest priced strength dosage form, form, dosage Medicine name, name, Medicine Aciclovir tab 200mg Albendazole tab 200mg Amitriptyline tab 25mg Amoxicillin cap 250mg Amoxicillin Susp 125mg/5ml Artemether/ Lumefantrine tab 20/120mg Bendruofluazide tab 5mg Betamethasone cream/ointment 1% w/v Carbamazepine tab 200mg Ceftriaxone 1g powder for inj Cimetidine tab 400mg Ciprofloxacin tab 500mg

26 No. 11: July-September 2013 omments and and omments observations C pack price Discounted Discounted for all? for Discount  %  %  % Yes  % Yes  %  %  %  %  %  %  %  %  % /ml /tab /tab /tab /tab /tab /tab /tab /cap / cap /Amp /bottle digits) Unit price (4 (4 price Unit Pack price found Pack size country of of country manufacture Manufacturer, Manufacturer, name) (brand / trade trade / (brand Product name Product es” or “N/ A ”) vailable? (“ Y A of interest Product Product Lowest priced Lowest priced Lowest priced Lowest priced Lowest price Lowest priced Lowest priced Lowest price Lowest priced Lowest priced Lowest priced Lowest priced strength dosage form, form, dosage Medicine name, name, Medicine Glibenclamide tab Glibenclamide 5mg Mebendazole tab 100mg Cotrimoxazole Susp 40/200mg/5ml Cotrimoxazole tab 480mg Dextrose 5% inj Diazepam tab 5mg Diclofenac tab 50mg Doxyclycline cap 100mg Erythromycin tab 250mg Fluconazole tab / cap 200mg Furosemide tab 40mg Gentamycin inj 80mg/2ml

27 MEDICINE P R I C E Monitor Uganda omments and and omments observations C pack price Discounted Discounted for all? for Discount Yes  % Yes  %  %  %  %  %  %  %  %  %  %  % /ml /tab /tab /tab /tab /tab /tab /tab /cap /sach /Amp digits) Unit price (4 (4 price Unit Pack price found Pack size country of of country manufacture Manufacturer, Manufacturer, name) (brand / trade trade / (brand Product name Product es” or “N/ A ”) vailable? (“ Y A of interest Product Product Lowest priced Lowest priced Lowest price Lowest priced Lowest priced Lowest priced Lowest price Lowest priced Lowest priced Lowest priced strength dosage form, form, dosage Medicine name, name, Medicine Metformin tab 500mg Methyergomet- rineinj 200μg/ml Metronidazole Susp 200mg/5ml Metronidazole tab 200mg Nifedipine retard tab 20mg Nystatinpessaries 100,000 I.U. Omeprazole cap 20mg Oral Rehydration Salt (ORS) Paracetamol tab 500mg Phenytoin tab 100mg Prednisolone tab 5mg

28 No. 11: July-September 2013 omments and and omments observations C pack price Discounted Discounted for all? for Discount  %  %  % Yes  % Yes  %  % /tab /tab /can /Amp /gram digits) Unit price (4 (4 price Unit Pack price found Pack size country of of country manufacture Manufacturer, Manufacturer, name) (brand / trade trade / (brand Product name Product es” or “N/ A ”) vailable? (“ Y A of interest Product Product Lowest priced Lowest priced Lowest priced Lowest priced Lowest priced strength dosage form, form, dosage Medicine name, name, Medicine Salbutamol inhaler 0.1mg/ dose eye Tetracycline ointment 1% Pyrimethamine/ Sulfadoxine tab 25/500mg Propranolol tab 40mg Quinine inj 300mg/2ml

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Annex 3: Availability of the 40 medicines in Urban versus Rural facilities across the sectors Medicine Urban Rural Public Private Mission Public Private Mission Aciclor tab 200mg 53% 80% 81% 47% 50% 68% Albendazole tab 200mg 26% 45% 38% 47% 15% 53% Amitriptyline tab 25mg 100% 95% 94% 89% 45% 74% Amoxicillin cap/tab 250mg 89% 100% 100% 79% 70% 84% Amoxicillin susp 250mg/5ml 11% 85% 88% 11% 65% 63% Artemether/Lumefantrine tab 20/120mg 89% 85% 81% 89% 65% 95% Bendrofluazide tab 5mg 68% 80% 88% 74% 25% 53% Betamethasone cream/ointment 1%w/v 16% 65% 44% 47% 55% 42% Carbamazepine tab 200mg 79% 85% 94% 84% 45% 53% Ceftriaxone 1g pwder for inj'n 84% 85% 94% 68% 50% 74% Cimetidine tab 400mg 0% 50% 25% 16% 25% 42% Ciprofloxacin tab 500mg 84% 95% 100% 79% 70% 89% Co-trimoxazolesusp 8/40 mg/ml 11% 70% 75% 21% 60% 42% Co-trimoxazole tab 400+80 mg 84% 80% 81% 95% 80% 89% Dextrose 5% inj 95% 60% 75% 74% 55% 79% Diazepam tab 5mg 95% 90% 81% 95% 70% 68% Diclofenac tab 50mg 68% 90% 88% 47% 100% 79% Doxycycline cap/tab 100mg 79% 80% 100% 74% 60% 100% Erythromycin tab 250mg 63% 80% 94% 63% 50% 68% Fluconazole tab /cap 200mg 26% 65% 56% 37% 10% 42% Furosemide tab 40mg 47% 85% 75% 74% 25% 58% Gentamycin inj 80mg/ml 58% 70% 88% 32% 55% 74% Glibenclamide tab 5mg 58% 85% 75% 53% 20% 53% Mebendazole tab 100mg 74% 90% 69% 79% 85% 84% Metformin tab 500mg 79% 90% 88% 63% 35% 47% Methyergometrineinj 200ug/ml 42% 30% 56% 47% 10% 47% Metronidazole susp 200mg/5ml 42% 45% 69% 47% 55% 58% Metronidazole tab 200mg 95% 95% 94% 89% 90% 100% Nifedipine retard tab 20mg 79% 90% 88% 79% 35% 63% Nystatinpessaries 100000iu 5% 75% 81% 21% 60% 47% Omeprazole cap 20mg 74% 85% 94% 58% 85% 74% Oral Rehydration Salt (ORS) 95% 90% 88% 84% 70% 89% Paracetamol tab 500mg 100% 95% 100% 79% 100% 100% Phenytoin tab 100mg 68% 50% 69% 84% 20% 47% Prednisolone tab 500mg 16% 95% 94% 16% 55% 58% Pyrimethamine /sulfadoxide (SP) tab 25/500mg 84% 65% 69% 74% 60% 74% Propranolol tab 40mg 37% 85% 88% 42% 45% 53% Quinimeinj 300mg/5ml 63% 60% 88% 26% 65% 63% Salbutamol inhaler 0.1mg(100mcg)/dose 5% 60% 50% 16% 25% 26% Tetracycline eye ointment 1% 84% 85% 63% 95% 35% 74%

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Annex 4: Median unit price of the 40 medicines in the urban versus rural facilities

Medicine Urban Rural Private Mission % price diff. Private Mission % price diff. Aciclor tab 200mg 300.0 350.0 -16.7 275.0 275.0 0.0 Albendazole tab 200mg 1000.0 700.0 30.0 400.0 #VALUE! Amitriptyline tab 25mg 100.0 100.0 0.0 100.0 100.0 0.0 Amoxicillin cap/tab 250mg 100.0 100.0 0.0 100.0 100.0 0.0 Amoxicillin susp 250mg/5ml 30.0 27.5 8.3 25.0 30.0 -20.0 Artemether/Lumefantrine tab 20/120mg 250.0 166.7 33.3 208.3 125.0 40.0 Bendrofluazide tab 5mg 100.0 100.0 0.0 150.0 100.0 33.3 Betamethasone cream/ointment 1%w/v 200.0 183.3 8.3 200.0 133.3 33.3 Carbamazepine tab 200mg 100.0 150.0 -50.0 200.0 100.0 50.0 Ceftriaxone 1g pwder for inj'n 2500.0 5000.0 -100.0 3000.0 3000.0 0.0 Cimetidine tab 400mg 200.0 150.0 25.0 200.0 200.0 0.0 Ciprofloxacin tab 500mg 300.0 275.0 8.3 250.0 250.0 0.0 Co-trimoxazolesusp 8/40 mg/ml 30.0 30.0 0.0 30.0 30.0 0.0 Co-trimoxazole tab 400+80 mg 100.0 85.0 15.0 75.0 100.0 -33.3 Dextrose 5% inj 2000.0 2000.0 0.0 2000.0 2000.0 0.0 Diazepam tab 5mg 100.0 100.0 0.0 100.0 100.0 0.0 Diclofenac tab 50mg 50.0 50.0 0.0 50.0 100.0 -100.0 Doxycycline cap/tab 100mg 100.0 125.0 -25.0 100.0 100.0 0.0 Erythromycin tab 250mg 200.0 200.0 0.0 200.0 150.0 25.0 Fluconazole tab /cap 200mg 1000.0 1000.0 0.0 600.0 #VALUE! Furosemide tab 40mg 100.0 100.0 0.0 50.0 87.5 -75.0 Gentamycin inj 80mg/ml 750.0 800.0 -6.7 800.0 700.0 12.5 Glibenclamide tab 5mg 100.0 100.0 0.0 100.0 100.0 0.0 Mebendazole tab 100mg 50.0 100.0 -100.0 50.0 75.0 -50.0 Metformin tab 500mg 200.0 200.0 0.0 200.0 100.0 50.0 Methyergometrineinj 200ug/ml 2000.0 1350.0 32.5 1000.0 #VALUE! Metronidazole susp 200mg/5ml 30.0 25.0 16.7 25.0 25.0 0.0 Metronidazole tab 200mg 100.0 100.0 0.0 50.0 50.0 0.0 Nifedipine retard tab 20mg 200.0 200.0 0.0 150.0 150.0 0.0 Nystatinpessaries 100000iu 357.1 292.9 18.0 200.0 300.0 -50.0 Omeprazole cap 20mg 300.0 300.0 0.0 200.0 200.0 0.0 Oral Rehydration Salt (ORS) 500.0 500.0 0.0 500.0 500.0 0.0 Paracetamol tab 500mg 50.0 50.0 0.0 30.0 50.0 -66.7 Phenytoin tab 100mg 100.0 100.0 0.0 75.0 100.0 -33.3 Prednisolone tab 500mg 100.0 70.0 30.0 50.0 50.0 0.0 Pyrimethamine /sulfadoxide (SP) tab 500.0 500.0 0.0 500.0 500.0 0.0 25/500mg Propranolol tab 40mg 100.0 100.0 0.0 100.0 50.0 50.0 Quinimeinj 300mg/5ml 1000.0 1100.0 -10.0 1200.0 1250.0 -4.2 Salbutamol inhaler 0.1mg(100mcg)/dose 8000.0 8000.0 0.0 8000.0 7500.0 6.3 Tetracycline eye ointment 1% 571.4 857.1 -50.0 428.6 428.6 0.0

31 For more information contact: HEPS-Uganda Coalition for Health Promotion & Social Development Plot 351A, Balintuma Road, Namirembe P.O. Box 2426, Kampala, Uganda Tel: +256-414-270970 Email: [email protected] Web: www.heps.or.ug

This work is licensed under http://creativecommons.org/licenses/by/3.0/ug/

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