study assessing prices, availability, and affordability of ... · dr harshbardhan nayak dr satyajit...

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)



>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)



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



31%

2%2%61%

4%

Manufacturer's selling price Stage 2: Landed price



31%

2%2%61%

4%




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%


Stage 3: Wholesale Stage 4: Retail


90%

5% 0%1% 4%


Stage 3: Wholesale Stage 4: Retail


23%

2%

4%

67%

4%




23%

2%

4%

67%

4%




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


Yes Highest-priced 15 /tab

No Lowest-priced 15 /tab





Yes Highest-priced 6 x1 /tab

No Lowest-priced 6X1 /tab

Yes Highest-priced /dose

No Lowest-priced /dose



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


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 1o tabs /gm

No Lowest-priced 10 tabs /gm











Availabletoday



Packsizefound

Price ofpack found


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


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 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 1 ml ampoule /ml

No Lowest-priced 1 ml ampoule /ml

Availabletoday



Packsizefound

Price ofpack found


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


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 /dose

No Lowest-priced /dose






No Lowest-priced 60 ml /ml State specific

Yes Highest-priced 6 /tab State specific

No Lowest-priced 6 /tab State specific



Availabletoday



Packsizefound

Price ofpack found


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)


Strength

No.

34.

35.

36.

37.

38.

39.

40.

OndancetronSyrup 2 mg / 5 ml

Valproic Acid200 mg / 5 ml


No Lowest-priced 30 ml /ml State specificNew


No Lowest-priced 100 ml /ml State specific

Availabletoday



Packsizefound

Price ofpack found


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)



(%)


(%)

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)



(%)


(%)

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.

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