The Prices of medicine in Sudan
The price of medicines is an important factor in determining access to effective treatment. Data on prices of medicines in public, private and other sector in different parts of Sudan are scarce. The objectives of this study were to measure prices of a chosen set of medicines in different health sectors in different sections of the country.
Methodology/Principal Findings: The methodology developed by the World Health Organization (WHO) and Health Action International (HAI) were used. four surveys were undertaken in each of Khartoum, Gadarif, North Kordofan and Northern state to assess the prices of selected essential medicines (n = 37- 41). For each medicine, data was collected for the Innovator Brand (IB) and the Lowest Priced Generic (LPG) at randomly selected public, private and other sector facilities and were compared with international reference prices (IRPs) to obtain a median price ratio. The procurement prices for generic medicines on average were 0.57, 1.88 and 2.63 times higher than the IRPs in each of Khartoum, North Kordofan and Northern, respectively. Public sector procures only generic medicines with retail prices 3.44 to 5.11 times higher than the IRPs, which were very high, compared to procurement prices. In private pharmacies, IB prices were 18.2 times higher than the IRPs, while generics were 5.31 times higher than IBs in Khartoum state. Few data were recorded for IB in Gadarif, North Kordofan and Northern state, while, generics were 4.35 to 4.66 times higher than IRP. No significant inter-sectoral or inter-state price variations were recorded in Sudan.
Conclusions/Significance: patients may not always benefit from low procurement prices achieved. Generic equivalents cost significantly less than innovator brands but medicine costs are still high compared with IRPs. This study will provide baseline information that can be used to assess effectiveness of country health policies
Key words; medicine, price, innovator, generic, Sudan, sector
Introduction
The prices of medicines are regarded as important factors which have a positive and significant impact on access to essential medicines and on the utilization of both public and private health care sectors [1]. The price of medicines has a large effect on people’s decisions about where to seek formal treatment [2]. High prices of medicines are a matter of concern world-wide especially in poor countries, where often patients have to pay for the full cost of medicines. In most low-income countries, the private sector is the main source of medicines in the health sector and out-of-pocket expenditure for individual is very high [3]. The countries where out-of-pocket expenditure is slightly lower are those with insurance schemes or other prepaid programmes [4]. In case of Sudan just fewer than 5% of households had benefited from insurance coverage. Woodward [5] states that border prices vary considerably between countries as a result of price discrimination by suppliers and due to the presence of a domestic pharmaceutical industry. There may also be price discrimination between different health sectors within the same country, e.g. to charge lower prices to the public and/or non-profit sectors than for the private-for-profit sector (6).
Sudan is the largest country in Africa (2.5 million square km) with a population of over 37 million. Sudan is classified by the World Bank as a low-middle-income country. With a 2005 per capita GDP of US$776, Sudan spent 3.8% of its GDP on health in 2005 with total health expenditure US$29 per capita. Out-of-pocket expenditure as percentage of private expenditure on health was 98% [7].
Health services are provided through different partners including federal and state ministries of health, private sector, nongovernmental organization (NGOs), armed forces, universities, and civil society. The procurement and distribution of medicines in the public health sector is performed by the commercialized (publicly-owned) Central Medical Supplies Public Organization (CMSPO) which Supplies various regional medical stores (RMS) for supply to distant health facilities. These health facilities may be independent or belong to a revolving drug fund (RDF) (a separate RDF is operated only in Khartoum State). The mark-ups levied by the public sector are not regulated and cross-subsidization is sometimes applied (8). Private sector importation of medicines is controlled under government regulation and the local national pharmaceutical industry produce 20% of national needs. In Sudan medicine prices are regulated in the private sector according to the regulations set for the registration of medicinal products in 1974.
There is a lack of information about prices of medicines in Sudan. No research is currently on process to provide reliable information on drug prices. The geographical access to essential medicine has been recently increased through the establishment of RDF programmes at 15 States in northern part of Sudan, but no information about the prices of medicines. The prices of medicines in Sudan are controlled since early sixties, but no researches done in the area of medicines prices. More over the Drug Regulatory Authority efficiency and bargaining power with pharmaceutical companies to negotiation and setting of private price medicines had not yet been assessed. So the data collected on prices are crucial for development of national pharmaceutical policies. This study will provide baseline information that can be used to assess effectiveness of country health policies for purposes of negotiations, differential and equity pricing and advocacy tools for NGOs, health professionals, and consumers while negotiating for equity and affordability of essential medicines. Objective of the present study was to measure prices for a selected set of medicines and to understand how prices vary by medicine type, sectors, regions (states) and facilities. We were also interested to compare medicines prices in different sectors with reference to MSH international reference prices.
Materials and methods
Study design
A cross sectional study was performed in four states; Khartoum state, North Kordofan state, Gedarif state and Northern state to collect and analyze data on medicines prices in Sudan.
Sampling
Included states and localities
Due to the large area of the Sudan the study was considered most appropriate to conduct multiple surveys in four acceptable regions of the country. The study was conducted in four different States located in north, east, west and the middle region of the country namely, Khartoum State, Gadarif State, North Kordofan State and Northern State. Khartoum state was selected purposely as a major urban centre of Sudan plus it considered fairly representative of middle part of the country, combined with other three states one from each region in the survey chosen randomly from the region’s lists of states.
Using this approach one central locality (the major urban centre) in each selected state was selected purposely combined with three other localities chosen randomly from a list of localities that can be reached within one day’s travel from the central area.
Included facilities
In each of the four identified localities, at least five public health facilities were selected, including the main public hospital. The choice of both private sector and other sector pharmacies sampled should be based on their proximity to the public health.
Only 11 health facilities were surveyed in IARA and NHIS in Khartoum state and Gadarif state, respectively. 20 public and 20 private health facilities each of Khartoum state and Gadarif states were include in the survey while 15 and 17 private medicines out lets and 14 and 19 public facilities were surveyed in North Kordofan and Northern state, respectively.
Included sectors
Background information on the health system and pharmaceutical sectors in the Sudan were collected before planning the survey. This information was used in the selection of sectors as well as for understanding the survey result and analysis.
Three sectors were selected to be included in the survey for price data collection. Those were public sector, private sector and NGO Islamic Relief Agency (IARA). IARA was selected as other sector in Khartoum state as it own the biggest number of health facilities (11 medicine outlets) among NGOs. While other sector selected in Gadarif state and Northern state was NHIF facilities. The NHIF was selected in these states due to the limited number of facilities per each NGO. In North Kordofan only two sectors were included (public and private). Hereafter, both health centers and hospitals will be collectively referred to as “public health facilities
(3) Medicines list
Medicines price study was carried out using the standard methodology developed by the World Health Organization (WHO) and Health Action International (HAI). This methodology requires a systematic survey of the prices of a core list of medicines and allows for a supplementary list of medicines that are selected on the basis of their importance in treating major national health problems. From the 30 medicines in the WHO/HAI core list, 22 medicines were found to be registered and available in Sudan. Unavailable medicines were deleted from the core list. Moreover twenty additional (supplementary list) medicines were chosen and added to the survey. The selection of the supplementary list medicines was based on national disease patterns, registration status in Sudan, the essential medicine list of Revolving Drug Fund of Khartoum State (RDFKS) and that of Regional Medical Stores (RMSs). It was also necessary that the medicine, dosage form, and strength had an international reference price. The supplementary list was finalized after national advisory group opinion. Fluconazole 200 mg capsule is on the WHO/HAI core list, but it is used in a different strength (150 mg) in Sudan. So it had been added to the supplementary list. The total number of medicines studied was 41 in Khartoum state and 37 in other three states with 34 medicines matched in both lists. These differences are due to different Essential Medicines List (EML) used in RMS and RDFKS. The prices of innovator brand and lowest price generic equivalents of defined medicines at selected health facilities were examined.
Data collection
Data collection was undertaken by pharmacists supervised by a senior pharmacist working to ministry of health at state level. Data collectors were well trained before the surveys; they undertook a pilot survey using the standardized forms prepared for the survey. Medicine Price Data Collection Form for patient price was prepared and revised with Innovator Brand (IB) while the Lowest Priced Generic (LPG) name was to be filled after being identified at each facility. A separate data collection form was used for Khartoum state, while a unified form were used in the other three states in the survey to enter the price of the medicine at the time of data collection. Procurement Prices were collected from Khartoum state Revolving Drug Fund (RDFKS) warehouse and from Regional Medical Stores (RMSs) at North Kordofan and Northern state. No data for procurement prices were recorded from Gadarif regional warehouse as they didn’t respond to data collectors.
Data entry
Medicine unit prices were entered into Medicines Price Workbook (Microsoft Excel spreadsheets), with double entry, auto-checking, and automated analysis features.
Data analysis
The Workbook software calculated and presented the price results in terms of Median Price Ratio (MPR). MPR was the comparison of the median price for each medicine across facilities with median unit price in the Management Sciences for Health 2004 Price Indicator Guide (the IRP) [10], converted into local currency. MPR for each medicine type in each sector was to be calculated, only if the medicine was available in at least four facilities. The workbook automatically generates summary tables and analysis such as MPRs of all medicines (IB, and LPG), median MPR, and inter-quartile range of MPRs, within-sector comparisons, and cross-sector comparisons.
A Median unit price for each medicine was calculated and then compared among the four states and among sectors for matched sets of medicines. A Kruskal-Wallis test was applied, and p, 0.05 was used to indicate a significant difference. And whenever there were only two groups, a Mann Whitney test was applied.
Cut-off points
In order to enable discussion in this study, the following cut-off points of MPRs were used: for public procurement price; MPR ≤ 1, for public sector patient price and other sector; MPR ≤ 1.5, and in case of private; MPR ≤ 2.5 (WHO, 2006). MPRs above these values were considered representing excessive local prices [11].
Study findings
Public sector prices versus IRPs
The MPRs for procurement and retail prices are presented in table 1. The IB medicines were not found in any of the regional warehouse visited at the time of conducting the survey. Procurement price data was available for 19 LPG medicines out of 41 medicines surveyed in Khartoum state, while they were 20 LPG medicines, and 28 out of 37 medicines surveyed in North Kordofan and Northern state, respectively. The procurement results shows a median price ratio of 0.52 in Khartoum state, 1.88 in North Kordofan state and 2.63 in northern state with an individual medicine MPR ranging from minimum to maximum: 0.1 to 1.43, 0.24 to 6.74 and 0.45 to 8.89 in these states, respectively.
Table 1: MPRs of LPG procurement and retail prices in the public sector
Khartoum state n=20
Gadarif
state n=20
N. Kordofan
state n= 15
Northern
state n= 19
P value
No. of medicines included in analysis
37
24
27
26
Median MPR for retail prices
(interquartile range)
4.78
(2.27 – 7.2)
3.49
(2.72 – 7.63)
4.98
(3.13 – 9.78)
5.11
(2.78 – 8.25)
0.58
Procurement median MPR
(interquartile range)
0.52
(0.18 – 0.58)
1.88
(0.92 – 3.38)
2.63
(1.31 – 4.25)
Generally the IBs medicines were unavailable at public sector facilities in the states surveyed. Hence, the patient price data was available only for LPG medicines in this sector. The median MPR for the LPG medicines was lowest for Gadarif state (MPR = 3.49) and highest for Northern state (MPR = 5.11). While it was 4.78 for Khartoum state and 4.98 in North Kordofan state, with half of the medicines (25th and 75th percentile) has MPR between 2.27 and 7.2 in Khartoum, 2.41 and 6.51 in Gadarif, 3.13 and 8.83 in North Kordofan and 2.78 and 8.25 in Northern state (Table 1).
Private sector retail prices versus IRPs
On average median retail price of surveyed medicine to a patient in Khartoum state was 18.2 times higher than the international reference price in case of IBs and 4.78 times higher in case of LPGs. The median MPRs for LPG product in Gadarif, North Kordofan and Northern state were found to be 4.66, 4.35 and 4.47, respectively (Table 2).
Table 2: MPRs of LPG and IB products in the private sector
Khartoum state
n=20
Gadarif state
n=20
N. Kordofan state
n= 15
Northern state
n= 17
IB
LPG
IB
LPG
IB
LPG
IB
LPG
No. of medicines included
16
41
2
32
3
33
8
34
Median MPR
18.2
5.31
7.15
4.66
10.57
4.35
12.16
4.47
25%ile MPR
11.08
3.02
5.44
2.81
7.02
2.77
8.2
2.90
75%ile MPR
45.98
10.43
8.85
10.17
13.28
9.45
26.55
8.86
Other sector retail prices versus IRPs
Only generic products were present in IARA and NHIF medical outlets and on average, were found to have median MPRs equal to 7.60 and 4.96 in IARA and NHIF, respectively (Table 3).
Table 3: MPRs of LPG and IB products in the other sector (IARA & NHIF)
IARA facilities
n=11
NHIF facilities
n=11
Medicines included
27
21
MPR
7.58
4.96
25% percentile MPR
3.33
3.18
75% percentile MPR
10.48
10.6
Inter-sectoral price comparison
In spite of low procurement prices observed in the procurement prices section, the prices paid by patients in public sector facilities in Khartoum state were nearly 10 times higher than the average procurement prices. While it was nearly 2.3 and 1.88 times higher in Kordofan state and Northern state respectively. But the result in Table 4 showed that, generally there is no significant difference in the price of LPGs across sectors in all states.
Table 4: MPRs variation across sectors in 4 states surveyed.
Public sector
Private sector
Other sector
P-value
State
LPG
LPG
Khartoum Median MPR*
4.78
5.31
7.58
.062
Gadarif Median MPR**
3.49
4.66
.591
N. Kordofan Median MPR**
4.98
4.35
.952
Northern Median MPR*
5.11
4.47
.927
(* Kruskal Wallis test, ** Mann Witnny test)
Variation in prices across states
The median MPRs for each medicines was generally appear to be quite stable a across the four states surveyed (Table 5). However median MPRs of some medicines showed varied across states. Those were loperamide, mebendazole and indomethacin.
Table 5: MPRs variation across 4 states surveyed.
Khartoum
Gadarif
North Kordofan
Northern
P-value
Public sector*
median MPR
4.78
3.44
4.99
5.11
0.589
Private sector*
median MPR
5.31
4.66
4.35
4.47
0.990
Other sector **
median MPR
7.58
0.390
(* Kruskal Wallis test, ** Mann Whitney test)
Discussion
Procurement prices versus MSH international reference prices (2004):
Regional Medical Stores (RMSs) procure their medicines at a high costs compared to international prices. The RDFKS prices compares favorably with international procurement. Procurement prices for generic products should be fairly close to MSH international supplier/tender prices (that is, ratio upto1.00) (11) These large difference in procurement prices between RMSs and RDFKS may be attributed in part, to the fact that the RDFKS procurement prices recorded in this study were collected as cost and fright (C&F) price while, RMS procure in-country mainly from CMSPO as well as from private importers and local manufacturers. So that these prices include taxes, fees, duties paid for imported medicine in addition to other mark-ups. The public sector in Sudan procured only generics, except one IB (salbutamol inhaler) was found in Khartoum public facilities. Generic procurement enhances the affordability and access to essential medicines.
The procurement prices of RDFKS were more or less identical with that in Yemen, Pakistan and Jordan. While in Lebanon, Syria and Pakistan procurement prices were higher than that of RDFKS (MPRs varied between 1.33 and 1.97) [12] but were comparable with that of RMS in North Kordofan. While in Northern state the public median procurement MPRs were substantially higher compared to all these countries. More examples were quoted from sub-Saharan African countries in which prices studies were conducted. Each of Ethiopia [13], Ghana [14], Kenya [15], Tanzania [16] and Uganda [17] had procurement prices comparable with that of RDFKS.
Comparison of patient’s prices with reference to IRPs
In Sudan, patient’s prices of both IBs and LPGs were expensive compared with IRPs in all sectors. Few medicines were found in private sectors within acceptable MPR range (MPR ≤ 2.5). They were 15% of medicines surveyed in Khartoum state, 24% in North Kordofan, 18% in Northern, and 16% in Gadarif. The median retail price of IBs was 18.2 times higher than the IRPs in private sector in Khartoum state which was closed to median MPR of innovator brands in Kuwait (MPR=17), a high income country of the EMRO region [18] and was higher than that in Ethiopia (MPR=13.6) a neighboring African country having socioeconomic level similar to Sudan[13].
Table 6: comparison of MPRS between Sudan and some countries
Public sector
(MPR)
Private sector
(MPR)
Sudan (Khartoum state)
4.78
5.31
Sudan (Northern state)
4.47
5.11
Sudan (North Kordofan state)
4.99
4.35
Sudan (Gedarif state)
3.44
4.66
Yemen
1.09
3.5
Pakistan
–
3.36
Syria
1.9
2.51
Kenya
1.99
3.33
Ethiopia
1.34
2.04
Uganda
–
2.6
This study results revealed that the prices of medicines in Sudan were very high compared to IRPs as well as to prices in countries around the Sudan (Table 6). It may be due to failure in pricing policy and price setting for private at regulatory authority.
As it appears the generic price might have been set to be discounted down from the originator rather than up from the procurement price and in turn the public sector set their prices close to the private sector prices. A drug pricing unit within the Federal Pharmacy and Poison Board should use public procurement as one of its reference prices in addition to international reference price such as those of MSH in the process of price setting in Sudan. Usually an individual country does not have much bargaining power with pharmaceutical companies and usually price is what market can bear. In addition local agent often barrier between Regulatory Authority and Pharmaceutical manufacturers [19].
Price variation across medicines:
Significant variations were there in prices in term of MPRs across the medicines surveyed in all sectors in Sudan. Excessive variation was observed in the private sector. This result indicates that the relative prices charged to patient for different medicines are not uniform when compared with IRPs. The difference in MPRs across medicines should be close to zero if same criteria were used for all medicines during price setting by the drug regulatory authority.
Prices variation between facilities
Variations of prices between public health facilities were small to moderate for most medicines in Khartoum state this may be due to reliance of the public to the RDF supply. While high medicine price variation were observed across public facilities in other states in the survey. It may be due to low RDF scheme coverage at these states [20] and as a result, procurement is decentralized to the facility level making it difficult for these medicine outlets to benefit from the CMSPO centralized procurements.
Some variability in MPRs of LPG products was found across private medicines outlets in all states. Generally private facilities show much variation than that in public and other sector in the survey. Variation in MPRs of LPG product was probably due to presences of several alternative generics.
Inter-sectoral
Overall there are no significant differences in the prices of medicines between sectors surveyed with this price of the same product often more consistent. The role of CMSPO may be in part behind the similarity of prices in all sectors as it was recently start selling medicine to all sectors instead of to only public facilities earlier. In spite of low procurement prices observed in the procurement prices section, the prices paid by patients in public sector facilities were nearly 10 times of the average procurement prices in Khartoum state. While, they were 2 times and 2.3 times average procurement prices in Northern state and North Kordofan state, respectively, which were much lower than in Khartoum state, but it means nothing if the procurement prices were initially very high in these two states.
Branded premium in private sector
By comparing the price of both innovator brand and its generic equivalent within the same sector, it is possible to determine how much extra the branded medicine costs (the brand premium). The brand premiums were discussed from Khartoum state private sector’s data due to unavailability or few data for IBs in public sector in other states, but still study of Khartoum state data will give a picture how the prices vary across both types of medicines (IB and LPG) in Sudan. In Khartoum state on average, a patient purchases IB medicine at a price 3.6 times the price of the equivalent LPG. Thus patients could save more than 72 % off the price of the IB by purchasing a generic, the case is better than that in Lebanon where patients could save more than 50% [21], this provides incentive for patients to use generic medicines.
But the huge differences in price between the IB and LPG, noted in the private sector in Sudan is not a big issue, because the generic is widely available and dispensed in Sudan.
Conclusion
Prices of medicines for innovator brand as well as generics were high in Sudan compared to international reference prices and to countries in sub-Saharan Africa, in spite of existing price regulations. The medicines price of the same products was generally consistent across States and across sectors. However the MPRs were variable across different medicines. IARA NGO facilities prices were higher than in the public sector and generally similar or occasionally higher than prices found in private retail pharmacies. Various policy measures could explore possibilities of reducing medicines prices by reviewing the pricing scheme for the private sector and reviewing the public medicine list according to patient needs and treatment guidelines.
Order Now