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Study assessing prices,
availability, and affordability of children’s medicine in Odisha,
India
This publication does not necessarily represent the decisions or policies of the World
Health Organization.
ii
Lead Organization:
Department of Pharmacology
S.C.B. Medical College& Hospital,
Cuttack ‐753007
Odisha, India
Project Team
Nodal Officer
Dr Trupti Rekha Swain
Area Supervisors
Dr Bandana Rath
Dr Suhasini Dehury
Dr Harshbardhan Nayak
Dr Satyajit Samal
Dr Anjali Tarai
Data Collectors
Dr Bandana Rath
Dr Dhaneswari Jena
Dr Abinash Panda
Dr Ayaskant Sahoo
Dr Ajitesh Sahu
Dr Suhasini Dehury
Dr Priti Das
Dr Rajashree Samal
Dr Satyajit Samal
Dr Gaurav Kumar
Dr Sansita Parida
Dr Anjali Tarai,
Dr Debasish Bisoi
Dr Santwana Mahar
Dr Monalisa Jena
Dr Harsavardhan Nayak
Dr Ramachandra Giri
Dr Himanshu S Sahu
Dr Sudhir Ku Parida
Data entry personnel
Dr Satyajit Samal
iii
Acknowledgements We are grateful to the Department of Health and F.W. Department of the Government of
Odisha for giving permission to conduct the study. We also wish to extend our thanks to the
Advisory Group:
Mrs A Garg, IAS, Commissioner cum Secretary, Health & F.W. Dept. Government of
Odisha
Professor PK Das, DMET, Odisha
Dr K Nayak, DHS, Odisha
Mr AS Das, Drugs Controller, Odisha
Dr K Nayak, Jt Director, State Drug Management Unit, Odisha
Dr RK Paty, Medical Officer, State Drug Management Unit, Odisha
Professor J Jena, Head, Dept. of Pharmacology, SCB Medical College, Cuttack
Professor CS Moharana, Head, Dept. of Pharmacology, MKCG Medical College,
Berhampur
Professor S Mohanty, Head, Dept. of Pharmacology, VSS Medical College, Burla
Professor B Mohapatra, Head, Dept. of Community Medicine, SCB Medical College,
Cuttack.
We are very thankful for the sincere cooperation and participation of the doctors,
pharmacists, and other staff at the medicine outlets during the process of data collection.
Health Action International and the World Health Organization provided technical support
for the survey and their assistance is gratefully acknowledged. Finally we convey our
heartfelt thanks to the following personnel for their valuable guidance and support
throughout the study:
Dr B Gitanjali, Technical Officer for Essential Drugs and Other Medicines, World
Health Organization, Regional Office for South‐East Asia, New Delhi
Dr A Kotwani, Associate Professor Department of Pharmacology, V.P. Chest
Institute, University of Delhi
Dr K Holloway, Regional Adviser, Essential Drugs and Other Medicines, World
Health Organization, Regional Office for South‐East Asia, New Delhi
Dr K Weerasuriya, Medical Officer, Medicines Access and Rational Use (MAR)
Essential Medicines and Pharmaceutical Policies (EMP), World Health Organization,
Geneva.
iv
Contents Abbreviations ...................................................................................................................................... v
Executive summary ............................................................................................................................. vi
1. Introduction ..................................................................................................................................... 1BetterMedicinesforChildrenproject.................................................................................................................................1Backgroundofthestate.............................................................................................................................................................2Administrativedivisions.............................................................................................................................................................2Healthsector...................................................................................................................................................................................3Pharmaceuticalsector................................................................................................................................................................4Financingandsourcesofmedicinessupply......................................................................................................................5Pharmaceuticalprocurement.................................................................................................................................................6Pricecontrolofmedicines.........................................................................................................................................................6
2. Methodology of the surveys ............................................................................................................. 7Overview...........................................................................................................................................................................................7Selectionofmedicineoutlets..................................................................................................................................................8Selectionofmedicinestobesurveyed.............................................................................................................................10Datacollection.............................................................................................................................................................................10Dataentry......................................................................................................................................................................................11Dataanalysis................................................................................................................................................................................11Pricecomponentssurvey.......................................................................................................................................................12
3. Results ........................................................................................................................................... 13Medicineavailability................................................................................................................................................................13Medicineprices...........................................................................................................................................................................19Publicsectorprocurementprices.......................................................................................................................................19Privatesectorpatientprices.................................................................................................................................................19NGO/Missionsectorpatientprices.....................................................................................................................................20
Affordabilityofstandardtreatmentregimens.............................................................................................................21Componentsofthepricestructure....................................................................................................................................22Privatesector...............................................................................................................................................................................22Publicsector.................................................................................................................................................................................25
Summary........................................................................................................................................................................................26
4. Conclusion ..................................................................................................................................... 29
5. References ..................................................................................................................................... 31
Annex 1. List of core and supplementary medicines surveyed ............................................................ 32
Annex 2. Medicine price data collection form used in the survey ....................................................... 33
Annex 3. Availability of individual medicines, in three sectors ........................................................... 39
Annex 4. Median price ratios, public sector procurement pricesa ....................................................... 41
Annex 5. Median price ratios, private sector patient pricesa ............................................................... 42
v
Abbreviations Cap Capsule
DFID Department for International Development
EML Essential Medicines List
HAI Health Action International
Inj Injection
MPR Median price ratio
MRP Manufacturer’s retail price
NGO Nongovernmental organization
ORS Oral rehydration solution
Rs Rupees
SDMU State Drug Management Unit
Susp Suspension
Tab Tablet
VAT Value added tax
WHO World Health Organization
vi
Executive summary A field study to measure availability, affordability and price components of selected
medicines was undertaken in Odisha, an eastern Indian state, using a standardized
methodology developed by the World Health Organization (WHO) and Health Action
International. The study was conducted as part of the WHO‐led Better Medicines for
Children project, funded by the Bill and Melinda Gates Foundation, which aims to improve
access to essential medicines for children by addressing issues of availability, safety, efficacy,
and price.
The survey of medicine prices and availability was conducted in six randomly selected
districts of Odisha: Cuttack, Ganjam, Sambalpur, Kalahandi, Kandhamal, and Balasore. Data
on 34 essential medicines were collected in medicine outlets in the public, private, and
NGO/mission sectors of each district, using a validated sampling frame. Data were also
collected on government procurement prices. For each medicine surveyed, data were
collected on the highest‐priced and lowest‐priced forms available on the day of visit to that
facility. Medicine prices are expressed as ratios relative to Management Sciences for Health
international reference prices for 2009 (median price ratio, MPR). Using the salary of the
lowest‐paid government worker, affordability was calculated as the number of daysʹ wages
this worker would need to purchase standard treatments for common conditions.
A price components survey was also conducted to identify the add‐on costs in the supply
chain that contribute to final patient prices. The survey included two types of data
collection: central data collection on official policies related to price components, and
tracking specific medicines through the supply chain to identify add‐on costs. Medicine
tracking was conducted in two regions: Cuttack and Balasore districts. Six medicines were
tracked backwards through the distribution chains in public and private sectors to identify
the add‐on costs that contribute to final price (final procurement price in the public sector
and final patient price in the private sector).
The results of the survey highlight a number of important issues, including the following
points.
Availability of medicines in the public and private sector
Mean availability of the 34 essential paediatric medicines in the public sector was 17.0%,
indicating that most patients must purchase medicines from the private sector. Highest‐
priced products were not found in the public sector, indicating that facilities were only
stocking one product for each medicine. In the private sector, the mean availability of
highest‐priced and lowest‐priced medicines was 10.8% and 38.5%, respectively. In the NGO
and mission sector, availability of children’s medicine was 21.8%
vii
When availability was analysed by therapeutic class, oral rehydration solution (ORS) for the
treatment of diarrhoea was the most prevalent, with availability of 85% or more in all three
sectors. However, dispersible zinc tablets were virtually unavailable (less than 5%
availability) in all three sectors. Antibiotics had variable availability depending on the
medicine and sector surveyed, though availability of individual medicines was consistently
less than 60% with the exception of ofloxacin. For the antiasthmatic class, Beclomethasone
inhalers were virtually unavailable (less than 5% availability) in all three sectors. Salbutamol
inhalers had higher availability in the public and private sectors (51.2% and 64.6%,
respectively), but were not available in the NGO/mission sector. No antiepileptics were
available in public sector facilities, while in the private sector availability ranged widely
from 1.2% for diazepam rectal solution to 42.7% for valproic acid oral liquid.
Public sector procurement prices
The Government of Odisha uses a central procurement system whereby medicines are
procured by an open tendering process. All the medicines in the government (public) sector
are procured as generic (branded generic) forms. In the public sector, the procurement
agency is purchasing medicines at prices 48% lower, on average, than international reference
prices, indicating a fair level of purchasing efficiency. Medicines procured by the
government are made available to the patients free of cost in public sector facilities.
Private sector patient prices
Both highest‐priced and lowest‐priced products were found in the private sector, indicating
that private sector facilities were sometimes stocking multiple products for individual
medicines. Both highest‐priced and lowest‐priced products were generally branded
generics, as originator brands are usually not found. On average, highest‐priced and lowest‐
priced products were being sold at 1.83 and 1.46 times the international reference price,
respectively. For some medicines, substantial price variation was observed across individual
outlets.
NGO/Mission sector patient prices
In NGO/mission sector facilities, medicines were found to cost 2.08 times their international
reference price. However due to low medicine availability results are based on four
medicines only. When the prices of these four medicines are compared with those in the
private sector, they are found to cost 12.4% more in the NGO/mission sector.
viii
Affordability of standard treatment regimens in the private sector
In treating common conditions using standard regimens, the lowest paid government worker
would need between 0.1 (fever, diarrhoea using ORS only) and 0.7 (respiratory infection) of one
day’s wages to purchase medicines from the private sector. While this could appear affordable,
this number does not includes costs associated with consultations and diagnostic tests. Further, a
majority people in Odisha earn significantly less than the lowest government wage. Finally, this
affordability indicator does not consider individuals or families with multiple medications.
Components of medicine prices
In the private sector, the cumulative mark‐up on branded generic products was
approximately 53% will little variation across individual medicines. The manufacturerʹs
retail price (MRP) is the largest contributor to the final patient price; in the case of
paracetamol, for example, the MRP contributed 65% to the final patient price. Larger
cumulative percentage mark‐ups are observed for unbranded rather than branded generics.
For example, for paracetamol suspension and ORS powder the cumulative per cent mark‐
ups of unbranded generics are 218% and 326%, compared to 53% for the brand product in
each case. For unbranded generics the retail mark‐up is the largest contributor to final
patient price (61% in the case of paracetamol). In the public sector, the MRP contributes 90%
to the final procurement price and add‐on costs (taxes and mark‐ups) contribute 10%.
The results of the survey show that the availability, price, and affordability of children’s
medicines in Odisha should be improved in order to ensure equity in access to basic medical
treatments, especially for the poor. This requires multi‐faceted interventions, as well as the
review and refocusing of policies, regulations, and educational interventions within the
state.
1
1. Introduction In September 2010, the Sriram Chandra Bhanja Medical College, Cuttack, conducted a state‐
wide study on the prices, availability, and affordability of a selection of medicines in
Odisha,1 India. These medicines were reviewed by product type (highest‐priced and lowest‐
priced), and compared with those in other sectors and countries. Those component costs
with the most significant contribution to the final price of medicines were categorized as
well. The study was conducted as part of the WHO‐led Better Medicines for Children
project, which aims to improve access to essential medicines for children by addressing
issues of availability, safety, efficacy, and price.
This study was conducted using an adaptation of the standardized methodology developed
by the World Health Organization (WHO) and Health Action International (HAI). The
WHO/HAI methodology is described in the manual Measuring medicine prices, availability,
and affordability and price components (1) and is accessible on the HAI website
(http://www.haiweb.org/medicineprices).
The main objectives of the study were to answer the following questions:
What is the availability of children’s medicines in the public, private, and
NGO/mission sectors?
Is the public sector purchasing children’s medicines efficiently in comparison with
international reference prices?
What is the price of children’s medicines in the public, private and NGO/mission
sectors, and how does this compare with international reference prices?
What is the difference in price of highest‐price and lowest‐price generic equivalents?
How affordable are medicines for the treatment of common conditions for people
with low income?
What charges get added to the price of medicines as they proceed from manufacturer
to patient?
Better Medicines for Children project
The Better Medicines for Children project was initiated by WHO in 2009 with funding from
the Bill and Melinda Gates Foundation. The overarching goal of the project is to improve
access to essential medicines for children by addressing issues of availability, safety, efficacy,
and price. Specific objectives include promoting their inclusion in national essential
medicines lists, treatment guidelines, and procurement schemes; working with drug
1 Formerly known as Orissa.
2
regulatory authorities to expedite regulatory assessment of essential medicines for children;
and developing measures to monitor and manage their prices.
Background of the state
Odisha lies on the eastern coast of India between 17.15’ and 22.45’ in the North latitude and
between 81.45’ and 87.50’ in the East longitude. The state is bound by Jharkhand on the
north, Chhattisgarh on the west, Andhra Pradesh on the south, and the Bay of Bengal on the
east. The state lies in a subtropical geo‐climatic region with vastly varied topography.
Odisha encompasses 155 707 square kilometres of land (4.74% of the country). Odisha is one
of the least urbanized states in India. The 2001 census places the rate of urbanization at
14.97. The scheduled tribe and scheduled caste populations constitute 22.13% and 16.53%
respectively of the total state population. This is comparatively higher than the total figures
for India (16.20% scheduled tribe and 8.19% scheduled caste, respectively).
The agriculture sector comprises about 80% of the total work force and contributes 50% of
the state’s domestic product. Rice is the principal crop. Its cultivation is the main occupation
of 75% of the people. The net state domestic product increased from Rs. 16 184.30 crores2 in
1993–1994 to Rs. 25 178.31 crores in 2004–2005. The per capita income has increased to Rs.
6555 in 2004–2005.
Odisha has been one of the most natural disaster‐prone states of India. Floods and droughts
regularly devastate the state and cyclones are common. Frequent occurrences of natural
calamities are barriers to economic progress.
Administrative divisions
Administratively Odisha has 3 revenue divisions, 30 districts, 58 subdivisions, 171 tehsils
and 314 community development blocks. There are 105 local bodies, 31 towns, 6235 gram
panchayats and 51 124 villages. Bhubaneswar is the capital.
In the three‐tier system of administration (Administrative Department, Heads of
Department, and District Offices and Subordinate Offices), department heads play a key role
between the Administrative Department and District Offices and Subordinate Offices. The
Director of Health Services in Odisha occupies a distinct position in the health care service
administration of the state pertaining to promotive, preventive, and curative aspects of
health care in the districts which have populations of one crore with 38% schedule
population. The Health & F.W. Department of the state formulates all health policies, and
the Director of Health Services, being the head of the department, executes them. Elements
of the national health programme are also executed in the state under the control and
supervision of the Director of Health Services.
2 One crore rupees equals US$ 10 million. US$ 1 ≈ 50 rupees.
3
Health sector
In 2009 the state’s per capita total expenditure on health was Rs. 263 (US$ 1 equals Rs. 45.2).
Tables 1 and 2 show various health indicators of Odisha, a state characterized by
widespread poverty and deprivation, where the population depends more heavily on public
health facilities than does the rest of the country. The utilization of public health facilities for
outpatient care in rural and urban areas is 51% and 54%, respectively, while the national
averages are 22% and 19%, respectively (2). Despite the public’s reliance on the public
system, evidence has highlighted huge gaps in the infrastructure of public health care, and
suggests that institutions do not operate at optimal levels (2).
In this context, it is important to discuss out‐of‐pocket expenditure and whether the state
government is able to protect Odisha’s large number of poor families from health shocks. As
revealed elsewhere (3), out‐of pocket‐expenditure represented 77% of total health
expenditure in 2001–2002, and slightly more, 80%, in 2004–2005. This huge percentage of
out‐of‐pocket expenses highlights the inadequate availability of public services and the great
burden placed on the poor in accessing medical services.
Table 1. Selected health indicators of Odisha
Indicator (reference)
Crude birth rate (4) 21 per 1000 population
Crude death rate (5) 8.8 per 1000 population
Infant mortality rate (3) 65 per 1000 live births
Infant mortality rate, urban (4) 46 per 1000 live births
Infant mortality rate, rural (4) 68 per 1000 live births
Natural growth rate (5) 13.1%
Total fertility rate (3) 2.4
Couple protection rate (3) 50.7%
Life expectancy at birth, 1996–2001 (7) 61.64 years
Maternal mortality rate ,2007-09 (5) 258 per 100 000 live births
Perinatal mortality rate (6) 65.3 per 1000 live & still births
4
Table 2. A selection of statistics of the health infrastructure of Odisha, 1999–2000
Doctor:population ratio 1:7560
Population:health facility 1:21 700
Nurse:doctor ratio 1:2
Bed:population ratio 1:2680
Auxiliary nurse-midwife:population ratio 1:5200
Medical college hospitals 6 (3 government & 3 private sector)
District headquarter hospitals 32
Subdivisional hospitals 22
Community health centres 231
Primary health centres 117
Primary health centres1 1162
Mobile health units 14
Specialized hospitals (e.g. TB, leprosy, eye, paediatrics)
120
Subcentres 6688
Total 8392
1 Lowest level govt. health facility staffed with one doctor, one nurse, and one pharmacist.
Pharmaceutical sector
The Government of Odisha has been implementing a series of management system changes
and reforms within the health sector, particularly in the Drug Controller Office, which is the
regulatory authority of medicines in the state. The Department for International
Development (DFID) in the United Kingdom of Great Britain and Northern Ireland has been
a key player in assisting the government of Odisha in this effort, which, among other things,
includes enhancing capacity to improve the supply of essential drugs.
Changes in pharmaceutical policy began in 1998. They were intended to restructure the drug
procurement and distribution system to make it more simple and efficient. Changes
included scale‐up of treatment protocols for selected diseases and streamlined warehouse
management, to make accessible to health facilities the maximum number of high‐quality
drugs. Other major features of this policy include the following:
A rational drug list contains essential items of drugs (generic products only).
An stringent quality control mechanism involves testing each batch of drugs
supplied.
Includes a drug budget and passbook system for all individual institutions.
5
Institutions can choose any drug in any quantity within budget and essential drug
list constraints.
Centralized drug procurement is from manufactures only, to ensure most
competitive prices.
Online inventory control system connects all warehouses with one central drug store
attached to the central office.
Twenty per cent of drug budget made available to the districts and peripheral
institutions for emergency purchase and meeting expenditure towards transport.
An awareness programme for physicians and pharmacists has been initialized for
rational drug use and better logistics.
Policy linked with other sector reform policies to establish treatment protocols, and
clinical audit practices.
Financing and sources of medicines supply
Implementation of a sustainable drug policy requires financial solvency. Continuous
availability of high‐quality drugs cannot be ensured without funding and the efficient use of
resources. Without these components the reality is that supply cannot meet demand.
Around the turn of the century, Odisha’s health budget hovered around 3% of the overall
budget (Table 3). Table 4 shows the normal rates for provisioning medicines to health
facilities.
Table 3. The health sector budget
Table 4. Budgets for various health facilities in Odisha
Outpatient dept. (>30 beds) Rs. 0.050 per patient/day Inpatient dept. (>30 beds) Rs. 9.50 per patient/day Area hospital (16–30 beds) Rs. 100 000 per day Community health centres (6–15 beds) Rs. 50 000 per day Block level primary health centre Rs. 30 000 per day Below primary health centre1 Rs. 16 000 per day
1 Lowest level govt. health facility staffed with one doctor, one nurse, and one pharmacist. Source: (8).
6
The requirement of funds for drugs determined on the basis of the above norms is Rs. 9.00
crores. The requirement as per projected demand is Rs. 12.00 crores in 2001–2002. Funds
allotted to the Deputy Director of Medical Stores in 2001–2002 were the following:
Central procurement: non‐plan 6.08 crores; plan 0.5309 crores.
DFID: Panchabyadhi3 0.93 crores; heat stroke 1.00 crores; sub health centre medicines
0.78 crores.
The World Bank (156 health facilities) and DFID (2 districts)4 provided additional funds, in
rupees, at the turn of the century as well:
World Bank 12 500 000 (1998–1999); 29 500 000 (1999–2000); 46 500 000 (2000–2001)
DFID: 2 020 128 (1998–1999); 3 810 892 (1999–2000); 2 886 761 (2000–2001).
Pharmaceutical procurement
Until 1997, the Director of Medical Education Training placed contract rates on suppliers for
various components of drugs. One or more suppliers were set along with the prices. The
chief medical officers of districts only placed orders with the suppliers for whom the rate
contract had been placed. Following a government order in 1997, the procurement methods
changed. The requirements of public health facilities were ascertained on the basis of
district‐wide indents, from which a state list was compiled. Tenders are called for supply of
specific quantities after receipt of bids and evaluation; following the prescribed approval
procedures, orders are placed on the selected bidders at pre‐approved prices. The revised
system was introduced to ameliorate deficiencies in the system prior to 1997, such as
irrational drug purchases (due to irregular and tardy funds), procurement problems in small
districts, and slow moving items/stock outs.
Price control of medicines
The Department of Chemicals and Petrochemicals of the Ministry of Chemical and Fertilizer
develops the pricing policy for the pharmaceutical industry in India. The prices of some
drugs are controlled through the Drug Price Control Order of 1995. Price controlled drugs
are divided into two categories: the first includes drugs considered as essential and is subject
to more stringent rules than those in the second category. Concessions on prices exist for
manufacturers who conduct in‐house Bulk drug research and development, and for new
drugs introduced into India, either by domestic or foreign firms.
3 The Panchabyadhi scheme is a guideline to treat the five most commonly occurring diseases in Odisha – malaria, leprosy, diarrhoea, acute respiratory infections, and scabies. 4 FID also provides funds for testing of quality and transportation of medicines.
7
The following initiatives have been taken by the Indian Government favouring the
pharmaceutical industry in the 2008–2009 budget:
a reduction in excise duty (from 16 to 8%) on all goods produced in the
pharmaceutical sector;
amounts spent on eligible for a 125% weighted deduction;
a reduction in customs duty (from 10 to 5%) and a total exemption of excise duty on
specified life‐saving drugs and bulk components used in the manufacture of anti‐
HIV/AIDS drugs;
central sales tax on specified life saving drugs reduced (from 3 to 2%);
value added tax (VAT): drugs and medicines are taxed at 4% (except Assam State
where the rate is 6%); and
a generous tax rate of 4% for medical devices (12.5% in the States of Maharashtra,
Gujarat & Kerala.
Odisha like few other states has introduced a system of levying tax on MRP at a single point,
that is, first sale in the state is subject to VAT on the basis of MRP and subsequent sales, in
general, are exempt. The MRP system is optional in some states. levy entry tax on entry of
medicines and devices in to these states. a national medicine price monitoring system for
retail/patient prices. There are no regulations mandating retail/patient medicine price
information to be made publicly accessible.
RationaluseofmedicinesOdishaʹs Essential Medicines List (EML), last updated in 2009, contains unique medicine
formulations and is currently being used for public sector procurement. There is a
committee responsible for the selection of products on the national EML. The first standard
treatment guideline was the Panchabyadhi scheme initiated in 2001. The next treatment
guideline was prepared in 2006.
2. Methodology of the surveys
Overview
The survey of the prices, availability, and affordability of medicines in Odisha was
conducted using an adaptation of the standardized WHO/HAI methodology (1). Data on the
availability and final (patient) prices of medicines were collected in medicine outlets in
public, private, and NGO/mission sectors. Government procurement prices were also
surveyed.
8
A total of 34 child‐specific essential medicines were surveyed, 23 from a core list
recommended by WHO and 11 medicines selected locally. For each medicine in the survey,
two products were monitored: the highest‐priced (either originator5 brand or branded
generic) and lowest‐priced6 All prices were converted to US dollars using the exchange rate
(buying rate) on the first day of data collection (15 September 2010): US$ 1 = Rs. 45.20.
Another survey was conducted alongside to identify additional costs contributing to the
final price of medicines. The survey included two phases: a pharmaceutical policy
investigation at the central level and review of the additional costs contributing to final price
along the medicine distribution chain. In the latter, a selection of survey medicines were
traced backwards through the supply chain, from dispensing point to importer or local
manufacturer, and different charges and mark‐ups were identified.
Selection of medicine outlets
Sampling was conducted in a manner consistent with the WHO/HAI methodology, which
has been shown through a recent validation study to yield a nationally representative
sample (8). In the first step, six districts in different geographical regions of the state were
randomly selected as survey areas for data collection. The major urban centre of each district
was selected as one survey area, and an additional five areas were chosen at random from
those which could be reached within a dayʹs drive from the headquarters of each district.
One district (Koraput from southern Odisha) was excluded from the selection of survey
areas due to political instability. The following six areas were surveyed (Figure 1):
Cuttack (medical college hospital and nodal point)
Sambalpur (western Odisha with medical college hospital)
Ganjam (southern Odisha with medical college hospital)
Kalahandi (rural district)
Kandhamal (tribal district)
Balasore (northern Odisha a rural district)
5 Originator brand child-specific medicines are usually not available in Odisha because of their high cost. 6 The lowest-priced medicines in the facility at the time of the survey.
9
Figure 1. Map of Odisha showing the districts chosen for the survey
In each survey area (district), the main public head quarter hospital and 13 other smaller
public health facilities constituted 14 sample survey areas. In each district this selection was
made from all public facilities expected to stock most of the medicines in the survey.
Fourteen private sector and two other facilities (e.g. NGO/Mission) within a four‐hour drive
from the main public hospital were also identified and surveyed (Table 5).
Table 5. Type and number of facilities or medicine outlets surveyed in each district
Public sector facilities (n=14)
Private sector facilities (n=14)
NGO/Mission sector (n=2)
Medical college hospital (if present) – 1
Retail pharmacies (chemist shops) – 8
Health facilities run by NGOs/mission sector – 2
District hospital – 1 Private clinics/Nursing homes/ Dispensing doctors – 6
Community health centres – 2 Primary health centres – 10
In total, 79 outlets were surveyed in each of the public and private sectors, and 5 outlets
were surveyed in the NGO/mission sector. While 12 facilities in the NGO/mission sector
were initially selected, only 5 were within one day’s drive and thus qualified for inclusion in
the study.
10
Selection of medicines to be surveyed
As part of the Better Medicines for Children project, 23 medicines in 30 different
formulations and strengths were recommended for inclusion in the survey. An additional 11
medicines were selected at the state level for inclusion in the survey. Supplementary
medicines were selected based on recommendations of the committee that was engaged in
the preparation of the child‐specific essential medicines list for the state. A few medicines
were excluded from the survey because they are available through restricted outlets only
(e.g. morphine tablets for oral use). Annex 1 list all the medicines surveyed. For each
medicine, a specific dosage form and strength was surveyed to ensure that data would be
comparable across facilities. In total 34 medicines were included in the survey, all of which
were expected to be available at the different levels of public sector facilities in the six survey
areas.
Data collection
The survey team consisted of a survey manager, 5 area supervisors, 18 data collectors, and 1
person to enter the data. All area supervisors and data collectors were faculty members and
post graduate students of pharmacology and community medicine departments, working in
three government medical colleges of the state. All survey personnel received training in the
standard survey methodology and data collection/data entry procedures at a workshop held
on 3 and 4 September 2010. As part of the workshop, a data collection pilot test was
conducted at public and private medicine outlets, which did not form part of the survey
sample.
Data collection took place between 15 September 2010 and 15 February 2011. Data collectors
visited medicine outlets in pairs and collected information on medicine availability and
price using a standard data collection form (Annex 2) specific to the medicines being
surveyed in Odisha. Area supervisors checked all forms at the end of each day of data
collection, and validated the data collection process. Each day, 20% of the medicine outlets
were independently surveyed and those results were compared with those of the data
collectors. Upon completion of the survey the survey manager conducted a quality control
check of all data collection forms prior to data entry.
Public procurement data were collected on the prices the government pays to procure
medicines. Data were collected for the same medicines as surveyed in medicine outlets.
Procurement data were obtained from the State Drug Management Unit (SDMU) in
Bhubaneswar, Odisha’s central medicine procurement agency.
To collect data on price components, six ‘tracer’ medicines were selected from the 34
medicines surveyed. The price of these medicines was tracked backwards, from sample
medicine outlets to central sources, to identify the different charges added to the price of the
medicine at each stage of the distribution chain. This was accomplished by contacting
wholesalers, suppliers, procurement officers, and ministry of health officials.
11
Data entry
Survey data were entered into the pre‐programmed MS Excel Workbook provided as part of
the WHO/HAI methodology. Data entry was checked using the ʹdouble entryʹ and ʹdata
checkerʹ functions of the Workbook. Erroneous entries and potential outliers were verified
and corrected as necessary.
Data analysis
The availability of individual medicines is calculated as the percentage of medicine outlets
where the medicine was found. Mean (average) availability is also reported for the 34
surveyed medicines. Note that the availability data only refer to the day of data collection at
each particular facility and may not reflect average monthly or yearly availability of
medicines at individual facilities. Medicine prices obtained during the survey are expressed
as ratios (median price ratios, MPRs) relative to a standard set of international reference
prices:
Median local unit price
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Medicine price ratio =
International reference unit price
The ratio is thus an expression of how much the local medicine price diverges from the
international reference price. For example an MPR of 2 would mean that the local medicine
price is twice that of the international reference price. Median price ratios were only
calculated for medicines with price data from at least four medicine outlets, except for
procurement prices where a single data point was accepted. The exchange rate used to
calculate MPRs was US$ 1 = Rs. 45.20; this was the commercial ‘buy’ rate taken from local
bank on the first day of data collection.
The 2009 Management Sciences for Health reference prices, taken from the International drug
price indicator guide (9), were used as the international reference prices in the survey. These
reference prices are the medians of recent procurement prices offered by profit‐making and
non‐profit‐making suppliers to international non‐profit‐making agencies for generic
products. These agencies typically sell in bulk quantity to governments or large NGOs, and
the prices are therefore relatively low as they represent efficient bulk procurement without
the costs of shipping or insurance. Price data were obtained at the start of the survey (15
September 2010) for each medicine surveyed.
Price results are presented for individual medicines, as well as for the 34 medicines
combined. Summary results for the combined medicines have provided a reasonable
representation of medicines in the country and price conditions on the market. As averages
can be skewed by outliers, median values have been used in the price analysis as a better
representation of the midpoint value. The magnitude of price and availability variations is
presented as the interquartile range. A quartile is a percentile rank that divides a
distribution into four equal parts. The range of values containing the central half of the
12
observations, that is, the range between the 25th and 75th percentiles, is the interquartile
range.
Finally, the affordability of treating six common conditions was assessed by comparing the
total cost of medicines prescribed at a standard dose, to the daily wage of the lowest paid
government worker (Rs. 277.42 at the time of the survey). Though it is difficult to assess true
affordability, treatments costing one day’s wage or less (for a full course of treatment for an
acute condition, or a 30‐day supply of medicine for chronic diseases) are generally
considered affordable.
Price components survey
Alongside the main survey, a price component survey was undertaken. Information on
government policies and regulations that affect price components was collected in the first
phase of the study from interviews with staff in various ministries and health‐care delivery
systems at the central level. In the second phase, data were collected on the actual price
components of a selection of the 34 survey medicines. Medicines were chosen to be
representative of different therapeutic classes and formulations, both acute and chronic
conditions, and those found to have large price variations across individual outlets (Table 6).
Table 6. Selected medicines for which price components were determined
Medicine Therapeutic class
Formulation Level of disease
Significant pricing
variation Amoxicillin/ Clavulanic acid
Antibiotic Dry syrup Acute Yes
Artemether + lumefantrine
Antimalarial Dispersible tablet Acute Yes
ORS sachet 1 litre Electrolyte Powder Acute Yes Paracetamol suspension
Antipyretic Suspension Acute Yes
Salbutamol inhaler
Antiasthma tic Metered-dose inhaler
Chronic Yes
Ofloxacin Antibiotic Tablet Acute Yes
To identify costs added to the base price of target medicines, each was tracked backwards
from the end of the supply chain (e.g. retail pharmacies in the private sector) to their point of
origin (manufacturers and importers). For each medicine, data were collected for both the
originator brand/branded generic product and a generic equivalent. The generic product
was the lowest‐priced generic most commonly found during the medicine prices and
availability survey. If this medicine was not available at a dispensing site, the next lowest‐
priced generic product available at the dispensing site was used.
Samples came from both the public and the private sector in the main urban area of
Bhubaneswar as well as in one rural survey area (Balasore) used in the medicine prices
survey. In each district, two dispensing sites were surveyed (one from both the private and
13
public sector). Survey sites were selected from the facilities used in the main medicine prices
survey based on the following criteria: 1) locations that sold medicines with the maximum
variation in pricing were chosen; 2) proximity to data providers (within one day’s drive);
and 3) integrity of data providers.
Dispensaries or private retail pharmacies were visited first, where information was
collected on the procurement price and the dispensing price, as well as any mark‐ups, taxes
and dispensing fees; from here the wholesaler or public sector supplier was identified for
each medicine. Identified wholesalers and public sector suppliers were then visited, and
data were collected on wholesale mark‐ups, local distribution costs, and any taxes collected.
Data collection proceeded in this manner for each medicine through each stage of the supply
chain, ending with the importer (for imported medicines) and the manufacturer (for locally
produced medicines).
The data collected on the prices of the components of medicines were analysed according to
five common stages of the supply chain:
manufacturer’s retail price (MRP) + insurance and freight (stage 1);
stockist / Carry & Forwarding agency landed price (stage 2);
wholesale selling price (private) or central medical stores price (public) (stage 3);
retail price (private) or dispensary price (public) (stage 4); and
Dispensed price (stage 5).
Analysis includes the cumulative per cent mark‐up at the end of each stage, the total
cumulative per cent mark‐up, and the per cent contribution of individual components to the
final medicine price. As medicines are provided to patients at no cost in the public sector,
add‐on costs represent the charges paid by Odisha’s SDMU.
3. Results
Medicine availability
Average availability of the lowest‐priced survey medicines in the public sector was low at
17.0% (Table 7). Average availability of lowest‐priced generics in the private sector was
better than in the public sector but was still relatively low (38.5%). Highest‐priced generic
branded products were also found in the private sector, with an average availability of
10.8% (Annex 3 lists the availability of each of the surveyed medicines in the private, public,
and NGO/mission sectors). Availability of lowest‐priced generics in NGO/mission sector
facilities was similar to that of the public sector (21.8%).
14
Table 7. Comparison of mean availability (%) of all surveyed medicines on the day of data collection, in three sectors
Public sector (n=82 outlets)
Private sector (n=82 outlets)
NGO/Mission sector (n=5 outlets)
Highest- priced
product
Lowest- priced
product
Highest-priced
product
Lowest- priced
product
Highest- priced
product
Lowest- priced
product Mean availability (standard deviation)
0.0% 17.0% (26.3%)
10.8% (17.9%)
38.5% (31.6%)
0.0% 21.8% (30.9%)
Table 8 contains the availability of individual medicines in each of the three sectors under
review. The essential medicines with the lowest availability (20% or less) in all three sectors
are:
Chloramphenicol powder for injection
Diazepam, rectal solution
Beclomethasone, inhaler
Zinc, dispersible tablet
Ferrous sulfate, suspension
Benzylpenicillin, injection
Isoniazid + rifampicin + pyrazinamide, dispersible tablet
Phenobarbital, injection
Procaine penicillin, injection
Carbamazepine, chewable tablet
Carbamazepine, chewable tablet and suspension
Phenytoin, suspension.
15
Table 8. Comparison of the availability of individual medicines, in three sectors
Availability (%)
Public (n=79 outlets)
Private sector (n=79 outlets)
NGO/Mission sector (n=5 outlets)
>75% Ofloxacin tab (200 mg), ORS (1 l).
Chloroquine syrup, ondansetron syrup, ofloxacin tab, ORS (1 l), albendazole susp, paracetamol susp.
Albendazole susp, chloroquine syrup, ORS (1 l), paracetamol susp.
50–75% Paracetamol susp, salbutamol inhaler, albendazole susp.
Amoxicillin + clavulanic acid syrup, salbutamol inhaler, vit A susp, predinisolone susp, azithromycin tab, ORS (200 ml).
Amoxicillin syrup, ondansetron syrup.
25–50% Amoxicillin susp, co-trimoxazole susp, chloroquine susp.
Amoxicillin + clavulanic acid tab, gentamycin inj, amoxicillin susp & dispersible tab, artemether + lumefantrine dispersible tab, valproic acid oral liquid, paracetamol tab, ibuprofen tab.
Azithromycin tab, ofloxacin tab, benzyl benzoate lotion.
<25% Azithromycin dispersible tab, beclomethasone inhaler, ferrous sulfate susp, vit A susp, zinc dispersible tab, amoxicillin dispersible tab, chloramphenicol powder for inj, Ibuprofen tab, ondansetron syrup, procaine penicillin inj, isoniazid + rifampicin + pyrazinamide dispersible tab, benzylpenicillin inj, paracetamol tab, benzyl benzoate lotion, gentamycin inj.
Diazepam rectal solution, beclomethasone inhaler, zinc dispersible tab, ferrous sulfate susp, benzyl benzoate lotion, benzylpenicillin inj, isoniazid + rifampicin + pyrazinamide dispersible tab, phenobarbital inj, procaine penicillin inj, carbamazepine chewable tab & susp, phenytoin susp, co-trimoxazole susp.
Chloramphenicol powder for inj, phenobarbital inj, co-trimoxazole susp, gentamycin inj, valproic acid oral liquid, amoxicillin + clavulanic acid dry syrup, ORS (200 ml).
0% Amoxicillin + clavulanic acid dry syrup, amoxicillin + clavulanic acid tab, artemether + lumefantrine dispersible tab, carbamazepine susp & chewable tab, diazepam rectal solution, ORS (200 ml), phenobarbital inj, phenytoin susp, prednisolone susp, valproic acid oral liquid.
Chloramphenicol powder for inj.
Diazepam rectal solution, beclomethasone inhaler, zinc dispersible tab, ferrous sulphate susp, benzylpenicillin inj, isoniazid + rifampicin + pyrazinamide dispersible tab, procaine penicillin inj, carbamazepine chewable tab, carbamazepine susp,
16
Availability (%)
Public (n=79 outlets)
Private sector (n=79 outlets)
NGO/Mission sector (n=5 outlets)
phenytoin susp, ibuprofen tab, amoxicillin + clavulanic acid tab, amoxicillin dispersible tab, artemether + lumefantrine dispersible tab, paracetamol tab, prednisolone susp, vit A susp, salbutamol inhaler.
Availability was also analysed by therapeutic class (Table 9). Oral rehydration solution
(ORS) (1 litre) for the treatment of diarrhoea was widely available – 85% or more in all three
sectors. dispersible zinc tablets, however, were scarce – availability was less than 5% in the
three sectors. Availability of antibiotics was variable depending on the type and sector
surveyed (Figure 2), though the class overall (with the exception of ofloxacin) was
consistently absent in over 60% of outlets with the exception of ofloxacin. Ofloxacin tablets
were the most widely available antibiotic across sectors (84.1%, 89.0%, and 40.0% of public,
private, and NGO/mission facilities, respectively). In the antiasthmatic group,
beclomethasone inhalers were scarce – less than 5% availability in all three sectors.
Salbutamol inhalers were more commonly found in the public and private sectors (51.2%
and 64.6%, respectively), but were not available in the NGO/mission sector. No
antiepileptics were available in public sector facilities, while in the private sector this
group’s availability ranged from 1.2% (diazepam rectal solution) to 42.7% (valproic acid oral
liquid) (Figure 3 and Annex 3).
17
Table 9. Availability of the surveyed medicines, by therapeutic class and sector
NSAIMs, nonsteroidal anti-inflammatory medicine.
THERAPEUTIC GROUP MEDICINEPublic (n=79)
Private (n=79)
Other (n=5)
Anti-anaemia medicines Ferrous sulfate suspension 2.4% 4.9% 0.0%Antiasthmatic Prednisolone suspension 0.0% 52.4% 0.0%Antiasthmatic Beclmethasone inhaler 2.4% 1.2% 0.0%Antiasthmatic Salbutamol inhaler 51.2% 64.6% 0.0%Antibiotics Amoxicillin + clavulanic acid dry syrup 0.0% 53.7% 20.0%Antibiotics Amoxicillin + clavulanic acid tab 0.0% 28.0% 0.0%Antibiotics Azithromycin dispersible tablet 1.2% 52.4% 40.0%Antibiotics Amoxicillin dispersible scored tablet 3.7% 34.1% 0.0%Antibiotics Chloramphenicol powder for injection 3.7% 0.0% 20.0%Antibiotics Procaine penicillin injection 6.1% 12.2% 0.0%Antibiotics Benzylpenicillin injection 9.8% 7.3% 0.0%Antibiotics Gentamycin injection 19.5% 31.7% 20.0%Antibiotics Amoxicillin suspension 32.9% 41.5% 60.0%Antibiotics Co-trimoxazole suspension 46.3% 23.2% 20.0%Antibiotics Ofloxacin 200 mg tablet 84.1% 89.0% 40.0%Antiemetics Ondansetron syrup/suspension 3.7% 89.0% 60.0%Antiepileptics Carbamazepine suspension 0.0% 18.3% 0.0%Antiepileptics Carbamazepine tab - chewable 0.0% 15.9% 0.0%Antiepileptics Diazepam rectal solution 0.0% 1.2% 0.0%Antiepileptics Phenobarbital injection 0.0% 11.0% 20.0%Antiepileptics Phenytoin suspension 0.0% 18.3% 0.0%Antiepileptics Valproic acid 0.0% 42.7% 20.0%Antimalarials Artemether + lumefantrine dispersible tab 0.0% 39.0% 0.0%Antimalarials Chloroquine suspension 42.7% 92.7% 80.0%Anti tuberculosis medicines Isoniazid+rifampicin+pyrazinamide disp. tab 8.5% 8.5% 0.0%Intestinal anthelminthics Albendazole susp 73.2% 95.1% 100.0%Medicines used for diarrhoea Oral rehydration solution (200 ml) 0.0% 72.0% 20.0%Medicines used for diarrhoea Zinc dispersible tab 2.4% 3.7% 0.0%Medicines used for diarrhoea Oral rehydration solution (for 1 lit) 91.5% 85.4% 100.0%NSAIMs Ibuprofen 200 mg tab 3.7% 25.6% 0.0%NSAIMs Paracetamol tab 250mg, scored 13.4% 45.1% 0.0%NSAIMs Paracetamol susp 54.9% 92.7% 80.0%Scabicides &pediculicides Benzyl benzoate lotion 19.5% 4.9% 40.0%Vitamins Vitamin A 2.4% 62.2% 0.0%
18
Figure 2. Availability of antibiotics in the public and private sector
Figure 3. Percentage availability of antiepileptics in the private sector
0 10 20 30 40 50 60 70 80 90 100
Amoxicillin + clavulanic acid dry syp
Amoxicillin + clavulanic acid tab
Azithromycin dispersible tablet
Amoxicillin dispersible scored tablet
Chloramphenicol powder for injection
Procaine penicillin injection
Benzylpenicillin inj
Gentamycin inj
Amoxicillin susp
Co-trimoxazole susp
Ofloxacin200mg tab
Private (n=79) Public (n=79)Percentage availability of medicines
0 10 20 30 40 50 60 70 80 90 100
Diazepam rectal solution
Phenobarbital injection
Carbamazepine Chewable tablet
Carbamazepine suspension
Phenytoin suspension
Valproic acid oral liquid
Availability (%)
19
Medicine prices
Public sector procurement prices
The Government of Odisha provides medicines free of cost to patients, but few of them are
child specific. The Government of Odisha procures medicines through its SDMU by open
tender method so that most reputed companies can participate in the tendering process. Of
the 14 medicines for which procurement prices were reported, it was found that the SDMU
is purchasing medicines at approximately half the international reference prices (MPR of
0.52) (Table 10), which indicates efficient purchasing.
Table 10. Ratio of median unit prices of selected medicines to international reference prices, public sector
Medicine type (n=14)
Median MPR
25th percentile
75th percentile
Minimum Maximum
Lowest-priced product 0.52 0.39 0.74 0.24 0.97
Private sector patient prices
In the private sector, lowest‐price generic medicines were being sold at 1.46 times their
international reference price (Table 11). Half of the lowest‐priced medicines were priced at
1.06 to 2.29 times their international reference price, which indicates moderate variation in
the median price ratios of individual medicines. Highest‐priced products were being sold at
1.83 times their international reference price, with similar variation across individual
medicines as observed with lowest‐priced generics. Some medicines also showed substantial
variation in the prices reported across individual private sector facilities (Table 12).
Table 13 shows the highest‐priced and lowest‐priced products of nine medicines. In the
private sector, highest‐priced products cost 24.5% more, on average, than their lowest‐priced
equivalents. Annex 4 lists public sector procurement prices and Annex 5 shows the median
MPR for the highest and lowest‐priced products of each of the surveyed medicines in the
private sector.
Table 11. Ratio of median unit prices of selected medicines to international reference prices, private sector
Medicine type Median MPR 25th percentile 75th percentile Highest-priced (n=9) 1.83 1.57 2.67 Lowest-priced (n=23) 1.46 1.06 2.29
20
Table 12. Medicines showing large price variations across outlets, private sector
Medicine name Medicine type
Median MPR
25th percentile
75th percentile
% difference between
percentiles
Ofloxacin tab Lowest-priced 2.15 1.89 2.83 50 Azithromycin dispersible tab Lowest-priced 1.47 1.20 1.86 55 Phenobarbital inj Lowest-priced 2.67 1.70 2.71 60 Albendazole susp Lowest-priced 1.27 1.27 2.41 91 Amoxicillin susp Lowest-priced 3.83 2.26 4.52 100 Amoxicillin + clavulanic acid tab Highest-priced 0.94 0.79 1.88 139 Amoxicillin + clavulanic acid tab Lowest-priced 1.29 0.65 1.75 170
Table 13. Median MPRs for highest- and lowest-priced medicines, private sector
Medicine type (n= 9)
Median MPR 25th percentile 75th percentile
Highest-priced product 1.83 1.57 2.67 Lowest-priced product 1.47 1.29 2.15
NGO/Mission sector patient prices
In NGO/mission sector facilities medicines were found to cost 2.08 times their international
reference price (Table 14). Due to low availability of medicines in this sector, however,
results are based on four medicines only. When the prices of these four medicines were
compared with those in the private sector, they were found to cost 12.4% more in the
NGO/mission sector (Table 15).
Table 14. Ratio of median unit prices of selected medicines to international reference prices, NGO/mission sector
Medicine type (n=4) Median MPR
25th percentile
75th percentile
Minimum Maximum
Lowest-priced medicines 2.08 1.48 2.80 0.68 3.95
Table 15. Comparison of MPRs for selected medicines found in private and NGO/mission sectors
Medicine type Median MPR private sector
Median MPR NGO/mission sector
% difference
Lowest-priced generic 1.85 2.08 12.4
21
Affordability of standard treatment regimens
The affordability of treatment for six common conditions was estimated as the number of
daysʹ wages of the lowest‐paid government worker needed to purchase medicines
prescribed at a standard dose. For acute conditions treatment duration was defined as a full
course of therapy, while for chronic diseases it was defined as a 30‐day supply of medicine.
The daily wage of the lowest‐paid government worker used in the analysis was Rs. 277.42.
Because of the extremely low availability of children’s medicine in the public sector most of
the patients are forced to purchase medicines from the private sector. For this and other
reasons many patients have little faith in government‐supplied medicines. In the private
sector, the affordability of both lowest‐priced and highest‐priced generics was reasonable for
all six conditions, with standard treatment costing less than a day’s wage (Table 16).
It should be noted that treatment costs refer to medicines only and do not include the
additional costs of consultation and diagnostic tests (10). Further, many people in Odisha
earn significantly less than the lowest government wage (approximately Rs. 150–200/day); as
such even treatments which appear affordable are too costly for the poorest segments of the
population. Finally, even where individual treatments appear affordable, individuals or
families who need multiple medications may quickly face unmanageable drug costs.
Table 16. Number of days' wages of the lowest paid government worker needed to purchase standard treatments for six conditions, private sector
— indicates unavailable.
Disease condition and standard treatment Private sector median treatment
price (Rs.)
Days’ wages
Childhood condition
Drug name, strength &
dosage form
Treatment schedule
Highest-priced
Lowest-priced
Highest-priced
Lowest-priced
Asthma Salbutamol 100 mcg/dose inhaler
1 inhaler of 200 doses
— 95.00 — 0.3
Worm infestation
Albendazole susp
200 mg/5 ml for two doses
5.12 2.60 0.09 0.05
Diarrhoea ORS (1 l) 1 packet for 24 hrs
14.90 14.25 0.1 0.1
Respiratory infection
Amoxicillin (125 mg) + clavulanic acid dry syrup (31.25 mg) for 30 ml
5 ml thrice daily for 7 days
35.14 32.76 0.7 0.7
Falciparum malaria
Artemether 20 mg + lumefantrine 120 mg
1 tab twice daily for 3 days
95.00 87.45 0.3 0.3
Fever Paracetamol suspension 125 mg/5 ml
5 ml thrice daily for 3 days
21.19 19.35 0.1 0.1
22
Components of the price structure
Private sector
The cumulative mark‐up on branded generic products was approximately 53% in the
private sector, with little variation across individual medicines (Table 17). Stage 2 charges
comprise central sale tax (2%) and entry tax (1%) as well as the stockist mark‐up (generally
3%). Wholesale and retail mark‐ups are represented in Stages 3 and 4, respectively, while the
4% VAT applied to all medicines is accounted for in Stage 5.
23
Table 17. Cumulative percentage mark-up of branded generic medicines in the private sector
Ofloxacin 200mg tab (Mankind)
Ofloxacin 200mg
tab (Alkem)
Salbutamol 100mcg/
dose inhaler
Paracetamol
125mg/ 5ml susp
ORS 20g powder
(Dr Reddy)
ORS 20g
powder (Manki
nd)
Amoxicillin/Clavulanic
acid 125mg + 31.25mg/5
ml dry syrup
(Ranbaxy)
Amoxicillin/Clavulanic
acid 125mg + 31.25mg/5ml dry syrup (Excare)
AL 20mg + 120mg
tab (Aristo)
AL 20mg + 120mg
tab (Suizer)
MRP (Rs.) 21.30 36.00 62.00 18.50 13.50 8.50 30.05 45.50 64.50 33.30 Stage 1 mark-up (%)
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Stage 2 mark-up (%)
6.57 6.08 6.00 6.00 6.30 6.12 5.99 6.00 6.00 6.00
Stage 3 mark-up (%)
11.01 11.00 11.00 11.01 11.01 10.98 10.99 11.01 11.00 11.00
Stage 4 mark-up (%)
25.00 25.01 25.00 25.08 24.98 24.98 25.01 25.01 25.00 25.00
Stage 5 mark-up (%)
4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00
Cumulative mark-up (%)
53.80 53.08 52.96 53.08 53.38 53.06 52.94 52.98 52.96 52.96
Final price (Rs.)
32.76 55.11 94.84 28.32 20.71 13.01 45.96 69.61 98.66 50.94
AL, Artemether + lumefantrine.
24
When the price components of originator brands/branded generics are compared to
unbranded generics, it can be seen that a much larger cumulative mark‐up is applied to the
latter (Table 18). For example, the cumulative mark‐up of unbranded generics for
paracetamol suspension and ORS powder were 218% and 326%, compared to 53% for the
branded generic product in each case. This is largely due to the difference in retail mark‐up
(stage 4) between originator brands/branded generics and unbranded generics as shown in
Table 18.
Table 18. Cumulative percentage mark-up of products in the private sector, branded generic and generic medicines
The difference between mark‐up structures of branded and unbranded products is also see
in Figure 4, which shows the percentage contribution of price components to final price. For
originator brand paracetamol suspension, the MRP is the largest contributor to final price
(65%). For the unbranded generic, the retail mark‐up is the largest contributor (61%), with
the MRP only accounting for 31% of the final price.
Paracetamol 125 mg/5 ml susp ORS 20 g powder for 1 l solution
Generic Branded generic Generic Branded generic
MRP (Rs.) 7.50 18.50 3.25 8.50 Stage 1 mark-up (%) 0.0 0.0 0.0 0.0
Stage 2 mark-up (%) 6.53 6.0 7.0 6.12
Stage 3 mark-up (%) 6.01 11.01 14.0 10.98
Stage 4 mark-up (%) 170.96 25.08 236.0 24.98
Stage 5 mark-up (%) 4.0 4.0 4.0 4.0
Cumulative mark-up (%) 218.24 53.08 326.25 53.06 Final price (Rs.) 23.87 28.32 13.85 13.01
25
Figure 4. Percentage contribution of price components to final price, private sector
Paracetamol suspension, originator brand Paracetamol suspension, unbranded generic
Public sector
Medicines are provided to patients at no cost in the public sector; thus, add‐on costs
represent the charges paid by the SDMU. The cumulative mark‐ups were approximately 10%
with only small variation observed across individual medicines (Table 19). The principal
contributors to this mark‐up were central sales tax and entry tax (3%), stockist mark‐up (2%),
and a VAT of 4%. Stage 1 represents the cost of international shipping (insurance and
freight); as these medicines were locally manufactured, it did not contribute to the final
patient price. Similarly charges applied at the wholesale level (stage 3) were not applicable
for medicines in the public sector.
Table 19. Cumulative percentage mark-up for generic medicines in the public sector
Ofloxacin 200 mg
tab
Salbutamol 100 mcg/dose
inhaler
Paracetamol 125 mg/5 ml
susp
ORS 20 mg powder
Manufacturer's retail price (Rs.)
8.00 48.00 4.40 1.80
Stage 1 mark-up (%) 0.00 0.00 0.00 0.00 Stage 2 mark-up (%) 6.00 6.00 6.00 5.00 Stage 3 mark-up (%) 0.00 0.00 0.00 0.00 Stage 4 mark-up (%) 0.00 0.04 0.77 0.53 Stage 5 mark-up (%) 4.00 4.00 4.00 4.00 Cumulative mark-up (%) 10.24 10.28 11.09 9.78 Final price (Rs.) 8.82 52.94 4.89 1.98
65%4%
8%
19%
4%
Manufac turer's selling price Stage 2: Landed price
Stage 3: W holesale Stage 4: Retail
Stage 5: Dispensed price
65%4%
8%
19%
4%
Manufac turer's selling price Stage 2: Landed price
Stage 3: W holesale Stage 4: Retail
Stage 5: Dispensed price
31%
2%2%61%
4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: W holesale Stage 4: Retail
Stage 5: Dispensed price
31%
2%2%61%
4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: W holesale Stage 4: Retail
Stage 5: Dispensed price
26
Figure 5 presents the mark‐up structures of unbranded generic ORS in the public sector and
branded generic ORS in the private sector. In the public sector the MRP contributes 90% to
the final procurement price, and the add‐on costs only contribute 10%. Conversely, in the
private sector MRP only contributes 23% and add‐on costs contribute 77%. This is generally
due to the retail mark‐up applied in the private sector (in this case contributing 67% to the
final price).
Figure 5. Percentage contribution of price components to final price for unbranded generic ORS in public and private sectors
Public sector Private sector
Summary
Results indicate that the procurement of medicines in general is relatively efficient in the
public sector, as shown by purchase prices lower than international reference prices.
However, the availability of children’s medicines in public sector facilities is poor: average
availability of all survey medicines was just 17.0%. The majority of the 34 child‐specific
medicines had extremely poor availability in public sector outlets (<25%), with the exception
of:
ORS, sachet (1 l) – 91.5%
Ofloxacin, tablet (200 mg) – 84.1%
Albendazole, suspension (200 mg/5 ml) – 73.2%
90%
5% 0%1% 4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: Wholesale Stage 4: Retail
Stage 5: Dispensed price
90%
5% 0%1% 4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: Wholesale Stage 4: Retail
Stage 5: Dispensed price
23%
2%
4%
67%
4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: W holesale Stage 4: Retail
Stage 5: Dispensed price
23%
2%
4%
67%
4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: W holesale Stage 4: Retail
Stage 5: Dispensed price
27
Paracetamol, suspension (125 mg/5 ml) – 54.9%
Salbutamol, inhaler – 51.2%
Chloroquine, syrup (125 mg/ml)– 42.7%
Co‐trimoxazole, dispersible tablet (100 mg + 20 mg) – 46.3%
Amoxicillin, suspension – 32.9%.
Given the low availability of medicines in the public sector, it can be concluded that many
patients must purchase medicines from the private sector or go without. In the private sector,
branded generics were the predominant product type found. Here, mean availability of the
highest‐priced and lowest‐priced medicines was 10.8% and 38.5%, respectively. Medicines
with particularly low availability (<25%) in the private sector totalled 13 and include:
Chloramphenicol for injection – 0.0%
Diazepam, rectal solution – 1.2%
Beclomethasone, inhaler – 1.2%
Zinc, dispersible tablet, 20 mg – 3.7%
Ferrous sulfate, suspension – 4.9%
Benzyl benzoate, lotion – 4.9%
Benzylpenicillin, injection – 7.3%
Isoniazid + rifampicin + pyrazinamide, dispersible tablet – 8.5%
Phenobarbital, injection – 11.0%
Procaine penicillin, injection – 12.2%
Carbamazepine, chewable tablet and suspension – 15.9% and 18.3%
Phenytoin, suspension – 18.3%
Co‐trimoxazole, suspension – 23.2%.
In the government (public) sector, availability of antibiotics was very low (<50% of facilities)
with the exception of ofloxacin (84.1% availability). For treatment of malaria, which
contributes to significant morbidity and mortality in children of Odisha, the government
procures chloroquine syrup and makes it available in only 42.7% of facilities. But the current
need is to procure artemisinin combination therapy (ACT) in appropriate child‐specific
dosages to reduce the high mortality rates of children in Odisha. For the management of
diarrhoea, ORS 1 litre solution was quite satisfactory with availability of 91.5%; conversely
ORS 200 ml solution was unavailable. Dispersible tablets of zinc are not procured by the
Government of Odisha and their availability is only 2.4%, which is accounted for through
local government purchases. The high availability of ofloxacin and ORS 1 litre solution in
28
government facilities suggests that one efficient mechanism of supply chain management
existing in Odisha can be exploited to supply life saving medicines.
In the private sector, the availability of antibiotics was slightly better compared to the
government sector. Unfortunately sufficient quantities of the key antimalarial medicine
artemether + lumefantrine were available in only 39% of facilities. Oral rehydration salts for
both 1 litre and 200 ml solutions were widely available in the private sector: more than 85%
of facilities carried the former and 72% carried the latter. Surprisingly, availability of zinc
dispersible tablets was only 3.7%.
In the public sector, medicines are procured centrally by the government and are available to
all patients at no cost. The public sector was found to be procuring medicines for reasonable
prices by international standards: the SDMU is purchasing medicines at approximately half
the international reference prices (median MPR of 0.52). In the private sector, patient prices
were on average higher than international reference prices, with median MPRs of 1.46 and
1.83 for lowest‐priced and highest‐priced products, respectively. Medicines were not found
to be priced consistently with respect to their international reference price. In the public
sector, half of lowest‐priced generic medicines were procured between 0.39 & 0.74 times their
international reference price. In the private sector, half of lowest‐priced generic medicines
were priced between 1.06 and 2.29 times their international reference price, while half of
highest‐priced medicines were priced between 1.57 to 2.67. The interquartile range for the
MPRs of individual medicines shows the variability in the medicine price across medicine
outlets. In the private sector price of some medicines vary considerably across outlets. The
high degree of variability between private sector outlets is likely the result of low market
competition and absence of proper price regulation.
In the private sector, all of the treatments studied cost less than the daily wage of the lowest
paid government worker regardless of whether highest‐priced or lowest price generics are
used. However, it should be noted that many people in Odisha earn much less that the
lowest government wage; as such even treatments which appear affordable are too costly for
the poorest segments of the population. Given that 42–47% (rural India) of the population are
living below the international poverty line of less than US$ 1/day, even treatments which
appear affordable are financially out‐of‐reach for a substantial number of people.
Add‐on costs, such as taxes, wholesale and retail mark‐ups, contribute substantially to the
final price of medicines in the private sector, particularly for unbranded generics. In the
private sector, add‐on costs represent 35% of the final patient price for branded medicines
and approximately 70% for unbranded generics. The largest contributor to add‐on costs is
retailer mark up. In the public sector, add‐on costs represent 10% of the final procurement
price for generics. These include central sales tax, entry tax, stockist mark‐up, and VAT of
4%.
29
The results of this survey provide insight into the availability, price, and affordability of a
selection of medicines in Odisha. The use of the WHO/HAI medicine prices survey has
allowed for the measurement of medicine prices and availability in a reliable and
standardized way that enables valid international comparisons to be made. A further
strength of the methodology are the multiple steps taken to ensure data quality: training of
survey personnel including a data collection pilot test; pairs of data collectors to cross‐check
results; double entry and verification of data into the computerized survey Workbook; data
checker function in Workbook that identifies outlier or erroneous entries; and quality control
checks at multiple stages.
Study results may be limited by the fact that data are inherently subject to outside influences
such as market fluctuations and delivery schedules. In addition, the reliability of median
price ratios is dependant on the number of supplier prices used to determine the median
Management Sciences for Health international reference price of each medicine. In cases
where very few supplier prices are available, or where there is no supplier price and the
buyer price is used as a proxy, MPRs can be skewed by a particularly high/low international
reference price. A further limitation is that availability is determined for the list of survey
medicines, and therefore does not account for the availability of alternate strengths or dosage
forms, or of therapeutic alternatives. Finally, the methodology does not include informal
sectors, such as markets and general stores, as the quality of the medicines found in such
sectors cannot be assured.
4. Conclusion The results of this preliminary analysis suggest that a mix of policies need to be implemented
to make medicines more available and affordable, particularly for the poor. Although further
investigation is required to obtain a more in‐depth understanding of the causes and
consequences of medicine pricing and availability, the results of this survey provide broad
directions for future research and action. The following recommendations outline the actions
to be taken to improve the availability and affordability of medicines in the state of Odisha.
Recommendation 1
The Government of Odisha should make procurement of children’s medicines a
priority, particularly for those used to treat diseases that contribute to the highest
morbidity and mortality of children in Odisha. Such medicines should be chosen
from Essential Medicines List of Children (EMLC).
Recommendation 2
Regulatory authorities should import more child‐specific formulations for the state.
Law should also make it mandatory to keep essential (and up‐to‐date) life‐saving
medicines in every medicine outlets both in public and private sectors.
30
Recommendation 3
The cost of medicines in the private sector should be lowered through targeted policy
change.
Recommendation 4
Looking at high morbidity and mortality among Odisha children, general physicians
should be trained to prescribe rationally for children. This should be achieved
through an extensive training programme involving doctors, pharmacists, and nurses
practising within the state.
Recommendation 5
An unbiased drug information centre, accessible by prescribing health‐care
professionals and pharmacists, should function on a regular basis.
Recommendation 6
Doctors should be urged to prescribe from the EMLC by periodic circular from the
Health Department of the Government of Odisha.
This study has helped to provide insight into the current state of the prices, availability, and
affordability of key medicines for the treatment of common conditions. The results highlight
priority areas for action for the ministry of health and others agencies in improving access to
affordable medicines. Debate and dialogue are now needed to identify how best different
players can contribute to enhancing accessibility to and affordability of essential medicines in
Odisha.
31
5. References 1. Measuring medicine prices, availability, affordability and price components. 2nd edition.
Geneva, World Health Organization/Health Action International, 2008
(http://www.haiweb.org/medicineprices/manual/documents.html, accessed 21
November 2011).
2. National Sample Survey Office, Ministry of Statistics and Programme Implementation of
the Government of India, New Delhi, 2006.
3. National Family Health Survey (NHFS‐3) report 2005‐2006. Mumbai, International
Institute for Population Sciences, 2006.
4. Sample registration system, 2009.
5. Sample registration system, Office of Registrar General, India
7th July 2011.
6. Sample registration system, 1997.
7. Official Website, Dept. Of Health and Family welfare, Govt. of Odisha
8. Evaluation of the Orissa Drug System: a study undertaken by Delhi Society for
Promotion of Rational Use of Medicine. [Bhubaneswar] 2002.
9. International drug price indicator guide. Arlington, VA, Management Sciences for
Health, 2009.
10. Cameron A et al. Medicine prices, availability, and affordability in 36 developing and
middle‐income countries: a secondary analysis. Lancet, 2009, 373:240–249.
32
Annex 1. List of core and supplementary medicines surveyed No. Medicine name, formulation and strength Target pack size Comment 1 Albendazole, suspension, 200 mg/5 ml 10 ml State specific 2 Amoxicillin, suspension, 125 mg/ml 60 ml 3 Amoxicillin, dispersible scored tablet, 250 mg 15 tabs 4 Amoxicillin + clavulanic acid, dry syrup, 125 mg +
31.25 mg 30 ml
5 Amoxicillin + clavulanic acid, dispersible kid forte, 250 mg + 125 mg, FC tablet
10 tabs
6 Artemether + lumefantrine, dispersible tablet, 20 mg + 120 mg
6 x 1
7 Beclomethasone inhaler 100 µg/dose 200-dose inhaler 8 Benzyl benzoate lotion 25% 100 ml State specific 9 Benzylpenicillin injection 600 mg (= 1 million IU) 1 vial 10 Carbamazepine, suspension, 100 mg/5 ml 100ml 11 Carbamazepine, chewable tablet, 100 mg 10 tabs 12 Chloramphenicol injection 500 mg/vial 1vial 13 Chloroquine, suspension, 50 mg/5 ml 60 ml State specific 14 Co-trimoxazole, dispersible tablet, 100 mg +
20 mg (also expressed as 400 mg + 80 mg) 10 tabs
15 Diazepam, rectal solution, 5 mg/ml 5 ml 16 Ferrous sulfate, suspension, 50 mg Fe/5 ml 150 ml 17 Gentamycin injection 10 mg/ml 2 ml ampoule 18 Ibuprofen, tablet, 200 mg 24 tabs 19 Isoniazid + rifampicin + pyrazinamide, dispersible
tablet, 50 mg + 100 mg + 300 mg 10 tabs State specific
20 ORS, sachet, 200 ml 1 sachet 21 ORS, sachet, 1 l 1 sachet 22 Paracetamol, suspension, 120 mg/5 ml or
125 mg/5 ml 60 ml
23 Paracetamol, scored tablet, 250 mg 10 tabs State specific 24 Phenobarbital injection 200 mg/ml 1 ml ampoule 25 Phenytoin, suspension, 25 or 30 mg/ml 500 ml 26 Procaine penicillin injection 1 g = 1 million IU 1 vial 27 Salbutamol inhaler 100 mcg/dose 200-dose inhaler 28 Vitamin A, capsule, 25 000 IU 30 29 Zinc, dispersible tablet, 20 mg 14 tabs 30 Prednisolone, suspension, 5 mg/5 ml 60 ml State specific 31 Azithromycin, dispersible tablet, 250 mg 6/10 tabs State specific 32 Ofloxacin, tablet, 200 mg 10 tabs State specific 33 Ondansetron, syrup/suspension, 2 mg/5 ml 30 ml State specific 34 Valproic acid, oral liquid, 200 mg/5 ml 100 ml State specific
33
Annex 2. Medicine price data collection form used in the survey
List of Medicines,Formulation,
Strength
No.
1.
2.
3.
4.
5.
6.
7.
8.
Albendazole,Suspension, 200mg/5ml
Amoxicillin,Suspension, 125mg/m l
Amoxicillin,Dispersible scoredtablet, 250 mg
Yes Highest-priced 10 ml /ml State specific
No Lowest-priced 10 ml /ml
Yes Highest-priced 60 ml /ml
No Lowest-priced 60 ml /ml
Yes Highest-priced 15 /tab
No Lowest-priced 15 /tab
Yes Highest-priced 30 ml /ml
No Lowest-priced 30 ml /ml
Yes Highest-priced 10 /tab
No Lowest-priced 10 /tab
Yes Highest-priced 6 x1 /tab
No Lowest-priced 6X1 /tab
Yes Highest-priced /dose
No Lowest-priced /dose
Yes Highest-priced 100 ml /ml State specific
No Lowest-priced 100 ml /ml
MEDICINE PRICE DATA COLLECTION FORM
Availabletoday
Medicine type Brand or productname(s)
Manufacturer Target packsize
Packsizefound
Price ofpack found
Unit price(4 digits)
Comment
A B C D E F G H I J
Amoxicillin+Clavulanic Acid,Dry syrup,125 mg + 31.25 mg
Amoxicillin/ClavulanicAcid,(250 +125mg ) FC tabs
Artemether +Lumefantrine,Dispersible Tabs,20 + 120 mg
Beclomethasone,Inhaler 100 μg/dose
Benzyl BenzoateLotion 25%
1 Inhaler200 doses
1 Inhaler200 doses
List of Medicines,Formulation,
Strength
No.
9.
10.
11
12.
13.
14.
15.
16.
Benzyl PenicillinInjection 600 mg =1 million IU
Carbamazepinesuspension100mg/5 ml
CarbamazepineChewable tablet100 mg
Yes Highest-priced 1 vial /vial
No Lowest-priced 1 vial /vial
Yes Highest-priced 100 ml /ml
No Lowest-priced 100 ml /ml
Yes Highest-priced 1o tabs /gm
No Lowest-priced 10 tabs /gm
Yes Highest-priced 1 vial /vial
No Lowest-priced 1 vial /vial
Yes Highest-priced 60 ml /ml State specific
No Lowest-priced 60 ml /ml
Yes Highest-priced 10 /tab
No Lowest-priced 10 /tab
Yes Highest-priced 5 ml /ml
No Lowest-priced 5 ml /ml
Yes Highest-priced 150 ml /ml
No Lowest-priced 150 ml /ml
Availabletoday
Medicine type Brand or productname(s)
Manufacturer Target packsize
Packsizefound
Price ofpack found
Unit price(4 digits)
Comment
A B C D E F G H I J
Chloramphenicolinjection 500mgvial
ChloroquineSuspension 50mg/ 5 ml
Co trimoxazoletablet(100mg+20mg)
Diazepam Rectalsolution 5mg/ml
Ferrous SulphateSuspension 50 mgFe/5ml
List of Medicines,Formulation,
Strength
No.
17.
18.
19.
20.
21.
22.
23.
24.
GentamicinInjection 10mg/ml
Ibuprofen Tablet200mg
Yes Highest-priced 2ml ampoule /ml
No Lowest-priced 2ml ampoule /ml
Yes Highest-priced 24 /tab
No Lowest-priced 24 /tab
Yes Highest-priced 10 tab /tab State specific
No Lowest-priced 10 tab /tab State specific
Yes Highest-priced 1 sachet /sachet
No Lowest-priced 1 sachet /sachet
Yes Highest-priced 1 sachet /sachet
No Lowest-priced 1 sachet /sachet
Yes Highest-priced 60 ml /ml
No Lowest-priced 60 ml /ml
Yes Highest-priced 10 tab /tab State specific
No Lowest-priced 10 tab /tab State specific
Yes Highest-priced 1 ml ampoule /ml
No Lowest-priced 1 ml ampoule /ml
Availabletoday
Medicine type Brand or productname(s)
Manufacturer Target packsize
Packsizefound
Price ofpack found
Unit price(4 digits)
StatespecificComment
A B C D E F G H I J
ORS Sachet SachetTo make 200ml
ORS Sachet Tomake 1 Litre
Paracetamol Suspen-sion 120mg/5ml OR125mg/5ml
Paracetamol scoredtab Tab 250 mg
PhenobarbitalInjection 200mg/ml
Isoniazid + Rifa+ PyznDispersible TabR ifampicin 100 mg + INH 50mg + Pyrazinamide 300 mg
List of Medicines,Formulation,
Strength
No.
25.
26.
27.
28.
29.
30.
31.
32.
PhenytoinSuspension25or30mg/ml
Procaine PenicillinInjection1 Gm = 1 Million IU
Yes Highest-priced 500ml /ml
No Lowest-priced 500ml /ml
Yes Highest-priced 1 vial /vial
No Lowest-priced 1 vial /vial
Yes Highest-priced /dose
No Lowest-priced /dose
Yes Highest-priced 30 /tab
No Lowest-priced 30 /tab
Yes Highest-priced 14 /tab
No Lowest-priced 14 /tab
Yes Highest-priced 60 ml /ml State specific
No Lowest-priced 60 ml /ml State specific
Yes Highest-priced 6 /tab State specific
No Lowest-priced 6 /tab State specific
Yes Highest-priced 10 tab /tab State specific
No Lowest-priced 10 tab /tab State specific
Availabletoday
Medicine type Brand or productname(s)
Manufacturer Target packsize
Packsizefound
Price ofpack found
Unit price(4 digits)
Comment
A B C D E F G H I J
Vit- A Capsules25,000IU
Zinc Tablet(dispersible) 20mg
Prednisolonesuspension ,5 mg /5 ml
Azithromycin 250mg Tab
Ofloxacin, 200 mgtabs
Salbutamol Inhaler100mcg/dose
1 inhaler(200 doses)
1 inhaler(200 doses)
List of Medicines,Formulation,
Strength
No.
34.
35.
36.
37.
38.
39.
40.
OndancetronSyrup 2 mg / 5 ml
Valproic Acid200 mg / 5 ml
Yes Highest-priced 30 ml /ml State specific
No Lowest-priced 30 ml /ml State specificNew
Yes Highest-priced 100 ml /ml State specific
No Lowest-priced 100 ml /ml State specific
Availabletoday
Medicine type Brand or productname(s)
Manufacturer Target packsize
Packsizefound
Price ofpack found
Unit price(4 digits)
Comment
A B C D E F G H I J
33
39
Annex 3. Availability of individual medicines, in three sectors
Medicine name National
EML (yes/no)
NGO/Mission sector (n=5
outlets)
Public sector (n=82
outlets)
Private sector (n=82 outlets)
Medicine availability
(%)
Medicine availability
(%)
Medicine availability (%)
All lowest-priced
products
All lowest-priced
products
Highest-priced
product
Lowest-priced
product Albendazole, suspension, 200 mg/5 ml
Yes 100.0 73.2 73.2 95.1
Amoxicillin, suspension, 125 mg/ml
Yes 60.0 32.9 2.4 41.5
Amoxicillin, dispersible scored tablet, 250 mg
Yes 0.0 3.7 3.7 34.1
Amoxicillin + clavulanic acid, dry syrup, 125 mg + 31.25 mg
Yes 20.0 0.0 23.2 53.7
Amoxicillin + clavulanic acid, dispersible kid forte, 250 mg + 125 mg, FC tablet
Yes 0.0 0.0 11.0 28.0
Artemether + lumefantrine, dispersible tablet, 20 mg + 120 mg
Yes 0.0 0.0 6.1 39.0
Beclomethasone inhaler 100 µg/dose
No 0.0 2.4 0.0 1.2
Benzyl benzoate lotion 25% Yes 40.0 19.5 0.0 4.9 Benzylpenicillin injection 600 mg (= 1 million IU)
Yes 0.0 9.8 0.0 7.3
Carbamazepine, suspension, 100 mg/5 ml
Yes 0.0 0.0 0.0 18.3
Carbamazepine, chewable tablet, 100 mg
No 0.0 0.0 1.2 15.9
Chloramphenicol injection 500 mg/vial
Yes 20.0 3.7 0.0 0.0
Chloroquine, suspension, 50 mg/5 ml
Yes 80.0 42.7 23.2 92.7
Co-trimoxazole, dispersible tablet, 100 mg + 20 mg (also expressed as 400 mg + 80 mg)
Yes 20.0 46.3 0.0 23.2
Diazepam, rectal solution, 5 mg/ml
No 0.0 0.0 0.0 1.2
Ferrous sulfate, suspension, 50 mg Fe/5 ml
Yes 0.0 2.4 2.4 4.9
Gentamycin injection 10 mg/ml
Yes 20.0 19.5 0.0 31.7
Ibuprofen, tablet, 200 mg Yes 0.0 3.7 0.0 25.6 Isoniazid + rifampicin + Yes 0.0 8.5 0.0 8.5
40
Medicine name National
EML (yes/no)
NGO/Mission sector (n=5
outlets)
Public sector (n=82
outlets)
Private sector (n=82 outlets)
Medicine availability
(%)
Medicine availability
(%)
Medicine availability (%)
All lowest-priced
products
All lowest-priced
products
Highest-priced
product
Lowest-priced
product pyrazinamide, dispersible tablet, 50 mg + 100 mg + 300 mg ORS, sachet, 200 ml Yes 20.0 0.0 22.0 72.0 ORS, sachet, 1 l Yes 100.0 91.5 36.6 85.4 Paracetamol, suspension, 120 mg/5 ml or 125 mg/5 ml
Yes 80.0 54.9 45.1 92.7
Paracetamol, scored tablet, 250 mg
Yes 0.0 13.4 2.4 45.1
Phenobarbital injection 200 mg/ml
Yes 20.0 0.0 0.0 11.0
Phenytoin, suspension, 25 or 30 mg/ml
Yes 0.0 0.0 0.0 18.3
Procaine penicillin injection 1 g = 1 million IU
Yes 0.0 6.1 0.0 12.2
Salbutamol inhaler 100 mcg/dose
Yes 0.0 51.2 2.4 64.6
Vitamin A, capsule, 25 000 IU
Yes 0.0 2.4 1.2 62.2
Zinc, dispersible tablet, 20 mg
Yes 0.0 2.4 0.0 3.7
Prednisolone, suspension, 5 mg/5 ml
Yes 0.0 0.0 1.2 52.4
Azithromycin, dispersible tablet, 250 mg
Yes 40.0 1.2 25.6 52.4
Ofloxacin, tablet, 200 mg Yes 40.0 84.1 31.7 89.0 Ondansetron, syrup/suspension, 2 mg/5 ml
Yes 60.0 3.7 48.8 89.0
Valproic acid, oral liquid, 200 mg/5 ml
Yes 20.0 0.0 2.4 42.7
41
Annex 4. Median price ratios, public sector procurement pricesa
Medicine name MPRs of a selection of lowest-priced generics
Albendazole, suspension, 200 mg/5 ml 0.31 Amoxicillin, suspension, 125 mg/ml 0.76 Amoxicillin, dispersible scored tablet, 250 mg 0.97 Amoxicillin + clavulanic acid, dry syrup, 125 mg + 31.25 mg — Amoxicillin + clavulanic acid, dispersible kid forte, 250 mg + 125 mg, FC tablet — Artemether + lumefantrine, dispersible tablet, 20 mg + 120 mg — Beclomethasone inhaler 100 µg/dose 0.24 Benzyl benzoate lotion 25% 0.38 Benzylpenicillin injection 600 mg (= 1 million IU) 0.92 Carbamazepine, suspension, 100 mg/5 ml — Carbamazepine, chewable tablet, 100 mg — Chloramphenicol injection 500 mg/vial 0.41 Chloroquine, suspension, 50 mg/5 ml — Co-trimoxazole, dispersible tablet, 100 mg + 20 mg (also expressed as 400 mg + 80 mg) 0.83 Diazepam, rectal solution, 5 mg/ml — Ferrous sulfate, suspension, 50 mg Fe/5 ml — Gentamycin injection 10 mg/ml 0.37 Ibuprofen, tablet, 200 mg 0.70 Isoniazid + rifampicin + pyrazinamide, dispersible tablet, 50 mg + 100 mg + 300 mg — ORS, sachet, 200 ml — ORS, sachet, 1 litre 0.52 Paracetamol, suspension, 120 mg/5 ml or 125 mg/5 ml 0.46 Paracetamol, scored tablet, 250 mg — Phenobarbital injection 200 mg/ml — Phenytoin, suspension, 25 or 30 mg/ml — Procaine penicillin injection 1 g = 1 million IU — Salbutamol inhaler 100 mcg/dose 0.64 Vitamin A, capsule, 25 000 IU — Zinc, dispersible tablet, 20 mg — Prednisolone, suspension, 5 mg/5 ml — Azithromycin, dispersible tablet, 250 mg — Ofloxacin, tablet, 200 mg 0.51 Ondansetron, syrup/suspension, 2 mg/5 ml — Valproic acid, oral liquid, 200 mg/5 ml —
a Comparison to reference prices and number of orders per medicine. — indicates this product had <1 order.
42
Annex 5. Median price ratios, private sector patient pricesa
Medicine name Median MPR,
highest-priced product
Median MPR, lowest-priced
product
Albendazole, suspension, 200 mg/5 ml 2.50 1.27 Amoxicillin, suspension, 125 mg/ml — 3.83 Amoxicillin, dispersible scored tablet, 250 mg — 5.78 Amoxicillin + clavulanic acid, dry syrup, 125 mg + 31.25 mg 1.57 1.46 Amoxicillin + clavulanic acid, dispersible kid forte, 250 mg + 125 mg, FC tablet 0.94 1.29 Artemether + lumefantrine, dispersible tablet, 20 mg + 120 mg 1.77 1.63 Beclomethasone inhaler 100 µg/dose — Benzyl benzoate lotion 25% — 3.08 Benzylpenicillin injection 600 mg (= 1 million IU) — 1.87 Carbamazepine, suspension, 100 mg/5 ml — 0.12 Carbamazepine, chewable tablet, 100 mg — 0.23 Chloramphenicol injection 500 mg/vial — — Chloroquine, suspension, 50 mg/5 ml 0.68 0.68 Co-trimoxazole, dispersible tablet, 100 mg + 20 mg (also expressed as 400 mg + 80 mg)
— 1.10
Diazepam, rectal solution, 5 mg/ml — — Ferrous sulfate, suspension, 50 mg Fe/5 ml — — Gentamycin injection 10 mg/ml — 1.02 Ibuprofen, tablet, 200 mg — 1.55 Isoniazid + rifampicin + pyrazinamide, dispersible tablet, 50 mg + 100 mg + 300 mg
— 1.14
ORS, sachet, 200 ml — — ORS, sachet, 1 litre 4.05 3.87 Paracetamol, suspension, 120 mg/5 ml or 125 mg/5 ml 2.67 2.44 Paracetamol, scored tablet, 250 mg — — Phenobarbital injection 200 mg/ml — 2.67 Phenytoin, suspension, 25 or 30 mg/ml — — Procaine penicillin injection 1 g = 1 million IU — — Salbutamol inhaler 100 mcg/dose — 1.15 Vitamin A, capsule, 25 000 IU — 0.13 Zinc, dispersible tablet, 20 mg — — Prednisolone, suspension, 5 mg/5 ml — 0.17 Azithromycin, dispersible tablet, 250 mg 1.83 1.47 Ofloxacin, tablet, 200 mg 2.83 2.15 Ondansetron, syrup/suspension, 2 mg/5 ml — — Valproic acid, oral liquid, 200 mg/5 ml — —
a Comparison to reference prices and percentage availability in outlets. — indicates this product was found in <4 outlets.