PLOS One journal recently published a 2009 study of the price, availability and affordability of ACTs and other anti-malarials in Sierra Leone. The methodology used was adapted from the WHO/HAI methodology. Data was collected from a total of 127 facilities (public, private and NGO sectors) across 6 of the 14 districts of the country. Key findings included over 95% availability in the public sector outlets of first-line AS+AQ for the treatment of uncomplicated malaria (where it was generally dispensed free-of-charge). Chloroquine was not found in any of the public sector outlets, highlighting its successful ban in this sector, however it was available in 70% of private pharmacies. 83% of the more rural retailers stocked non-policy anti-malarials, which were offered at a much lower price than ACTs. The authors concluded that the widespread availability of ACTs in the public sector can be expected to discourage the sale of monotherapies, counterfeit and substandard anti-malarials by the private sector but effective measures are needed to strengthen the drug distribution system to control the widespread availability of banned chloroquine in the private sector in particular, and to counter the lack of availability and high cost of policy anti-malarials in the private sector, which undermines the anti-malarial market.

Click here to access the journal article

In 2011 Margaret Ewen from HAI and Maisa Al Sakit, an independent consultant from Jordan, assessed medicine procurement processes and prices in the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). Analysis of the data showed procurement responsibilities are well defined, procedures are followed and central procurement adheres to UNRWA’s formulary. But the criteria and processes for prequalifying suppliers were not clearly defined, there were few requirements for testing product quality, quantification was not based on need, and awarded prices were not reported or shared with bidders. Overall, UNRWA’s central procurement prices did not differ from reference prices i.e. Management Sciences for Health’s International Drug Price Indicator Guide, and awarded tenders from Jordan’s Joint Procurement Department and the Gulf Cooperation Council. The recommendations of the authors included the establishment of regulatory standards for supplier prequalification and product quality assurance, and the publishing of awarded tender prices to increase competition and transparency.

Click here to access the abstract of this study published by The Lancet, 8 October 2012
Click here to access the abstract in Word
Click here to access the full report

Based on findings from medicine price and availability surveys from 2007-2011, the 2012 UN MDG Gap Task Force reports little improvement in recent years in the availability and affordability of essential medicines in developing countries. On average, the availability of generic medicines was 51.8% in public sector medicine outlets and 68.5% in private pharmacies, with some countries having significantly lower availability. Overall patient prices of lowest priced generics in the private sector were about five times the international reference prices, with some countries over ten times. The UN concluded that obtaining essential medicines, especially for the treatment of chronic diseases, remains prohibitive for low-income families in developing countries.

Click here to access the report
Click here to access the press release

As part of the WHO/HAI review of generics policies (in progress), Warren Kaplan, Veronika Wirtz and others reviewed the literature - published from 2000 to 2010 - on the impact of policies to enhance use of generics in low and middle income countries (LMICs). They found only 10 evaluations of the impact of competition, trade, pricing and prescribing policies on generic medicine prices and/or volume. Key barriers to implementing generics policies in LMICs were negative perceptions (eg generics are lower quality), perverse incentives for retailers to sell products with the highest profit margin, absence of regulations permitting generic substitution, and lack of price transparency. Despite limited evidence, the authors concluded that prerequisites for increasing the use of generics were a functioning regulatory authority, a robust generics market, and aligning incentives for doctors, consumers and retailers.

Click here to access the paper in Health Policy

Data from three new medicine price and availability surveys have recently been added to the database:

Haiti, August 2011

Price and availability data was collected in four sectors (public, private, NGO and a mixed sector) across all 11 provinces of the country. Mean availability was poor at 20% in the public sector, 37% in the private sector and 23% in both the NGO and mixed sectors (generics). Patient prices were particularly high in the public and private sectors at 4.77 and 7.25 times international reference prices respectively for lowest priced generics. While the availability of originator brands in the private sector was low at 5%, they were very high priced (median price 35 times IRP) and unaffordable for those on low wages. Even some lowest priced generics were unaffordable e.g. the lowest paid government worker would have to work 5.3 days to pay for 30 days’ supply of phenytoin for epilepsy. Recommendations included adopting and disseminating the national Essential Medicine List (and ensuring the availability of medicines on this list in public sector facilities), and assessing the supply chain to identify areas where regulations are needed to make medicines more affordable.

Click here to access the survey report

In this survey data was collected on 95 medicines (predominantly for CV disease) in the public and private sector of 5 regions in Tatarstan province in Russia. Mean availability was good at 89% in the public sector and 75% in the private sector (generics). Government procurement prices were very high at 12.32 and 2.92 times international reference prices (IRP) for originator brands and lowest-priced generics respectively. Patients paid slightly less in public sector facilities (but still at high prices). In private pharmacies patients paid 12.56 and 3.98 times IRP for originator brands and lowest-priced generics respectively. No survey report is currently available.

Data was collected in the public and private sectors in all 8 districts of NCT, Delhi. Mean availability of EML medicines in the public sector (where medicines are free-of-charge) was 48.8%. Overall government procurement prices were reasonable but prices were highly variable for some medicines across the 5 agencies procuring medicines showing procurement could be more efficient. Private sector patient prices ranged from 44% below international reference prices (IRP) to 1500% for individual medicines. Median prices for lowest priced generics were 2.83 times IRPs. Trade schemes between the manufacturer, wholesaler and retailer, such as ‘buy 10 and get 2 free’, were found for 3 of the 7 medicines in the analysis, retail mark-ups were higher than established mark-ups, and 5% VAT is applied to medicines. Policy options recommended by the author include reviewing how manufacturers set the maximum retail price and transparency of procurement prices across agencies.

Click here to access the survey report

Reliable, accessible, potentially cheap and effective treatments with generic medicines for the majority of non-communicable diseases (NCDs) such as cardiovascular disease, diabetes and asthma are within our grasp. But low availability, and high prices of originator brands and even some lowest-priced generics, put them out-of-reach of the majority of the world’s poor. HAI calls on delegates at the UN High Level Meeting on NCDs on 19/20 September 2011 in New York to refocus on the attainable goal of universal access to essential medicines as a core priority for the treatment of NCDs. Donors need to recognise the paucity of support for essential medicines initiatives, globally, regionally and nationally, such as those by WHO, civil society and governments. In the longer term, donors should consider scaling-up support to establish a Global Fund for Essential Medicines for Non-Communicable Diseases that promotes universal access to low-priced generic medicines of assured quality.

Click here to read HAI's briefing note on access to medicines for non-communicable diseases

On 11 May 2010 people from 60 countries collected the price a patient would have to pay (if they paid the full price) for a 10 ml traditional vial of 100IU/ml soluble human insulin injection (neutral, regular) in their closest private retail pharmacy. This one-day snapshot of the price of insulin is the second in the series – on 30 November 2009 a snapshot was taken on the price of a course of ciprofloxacin 500mg tablets.

The map above shows prices in US$ for each brand of soluble human insulin found in the pharmacy on 11 May 2010 (10ml traditional vial only). If you click on the ‘bubble’, a text box will give the location, brand, manufacturer and the price of the insulin. Unlike the snapshot of ciprofloxacin prices, in the map all brands of insulin have been considered as originator brands (it appears that Eli Lilly and Novo Nordisk first marketed insulin at about the same time).

These prices should not be considered representative of the situation in a given country, since great price variation exists within some countries. However, they are indicative of what patients would have to pay, if paying the full retail price, in those pharmacies on that day.

As can be seen on the map, prices vary considerably across countries and between brands; from US$1.55 in Iran to US$76.69 in Austria – a difference of almost 5000%. While patient prices are often lower in low-income countries, the prices in some low- and middle-income countries are higher than in high-income countries. Even when prices are lower, insulin is still unaffordable for those on low incomes - which is often the majority of the population - resulting in dire consequences for people with diabetes if they cannot afford to buy the medicine.

Nearly ninety years after its discovery, access to insulin is beyond the reach of millions of people with diabetes around the world. Access to insulin is an essential and non-negotiable need, in short, a matter of life or death. Governments need to examine access to affordable insulin and give it the priority it deserves.

The first step is understanding the medicine price, availability and affordability situation, for example through undertaking a medicine price and availability survey (click on ‘Undertaking a survey’ above), then identifying the causes of high prices and poor availability, developing and implementing policies and strategies, and monitoring their impact to ensure patients benefit from lower prices and improved availability.

Click to access the following:

• an analysis of the results and recommendations
• charts showing the average price of a 10ml vial of soluble human insulin in US$ across the 60 countries where data was provided: Eli Lilly insulin, Novo Nordisk insulin, all manufacturers
• table of all data collected

Click here for information on the 30 November 2009 global snapshot of the price of a course of ciprofloxacin 500mg tablets.