ASSESSMENT OF AVAILABILITY, PRICE AND AFFORDABILITY OF MEDICINES FOR CHILDREN IN GHANA Authors: Gyansa-Lutterodt M. 1,Andrews Annan E. 2, Koduah A. 1, Asare A.B. 1 1 Ghana National Drugs Programme 2 World Health Organisation/Ghana

Equitable access to essential medicines for children and their rational use is a preceding step in achieving the country and global targets on child mortality. Infant and under five mortality rates are estimated at 50 and 80 respectively per 1000 births in Ghana. Ghana’s under 5 mortality remains high (111/1000 live births in ). Declines in mortality that began in the 1980’s have slowed. Most of these deaths are preventable by access to safe essential child-specific medicines with the necessary framework for their rational use. Introduction

BUKINA FASO TOGO COTE D’IVOIRE A T L A N T I C O C E A N Regional Population (2010 Census) RegionPopulation% of Total Population Upper West677,7632.8% Upper East1,031,4784.3% Northern2,468, % Brong-Ahafo2,282,1289.4% Ashanti4,725, % Western2,325,5979.6% Central2,107,2098.7% Eastern2,596, % Greater Accra3,909, % Volta2,099,8768.7% National 24,223,431100% Under 18 (est.)11,505, % 18 – 69 (est.)12,075, % 70 & above (est.)652,8682.7% Source: Ghana Statistical Service. Provisional results of 2010 Census

High infant and under 5 child mortality

Known causes of death

The Better Medicines for Children Project The BMC project, initiated by the World Health Organization in 2009 with funding from the Bill and Melinda Gates Foundation seeks to increase access to child specific medicines within the framework of existing country policy. The project is also to support country efforts to achieve the Millennium Development Goals (Goals Four and Six). The Better Medicines for Children (BMC) project is implemented in Ghana through the Ghana National Drugs Programme of the Ministry of Health.

Strategic Objectives of the BMC Project Promoting access to essential medicines for children Advocating for their inclusion in national essential medicines lists, treatment guidelines, NHI and procurement schemes with policy makers. Working with drug regulatory authorities to expedite regulatory actions on selected medicines for children; Developing measures to monitor and manage their prices.

Measure the availability of child- specific medicines in Ghana; Evaluate and compare prices of child-specific medicines in the public, private and mission sectors to government procurement prices; Evaluate the affordability of child- specific medicines in Ghana. Objectives of the study

The survey of medicine prices and availability was conducted in three regions, namely: Greater Accra, Ashanti and Upper West Regions. Data on 30 child-specific medicines (38 formulations) were collected in 18 public and 42 private sector medicine outlets (including four mission drug outlets). Data was also collected on government procurement prices for the selected medicines. For each medicine in the survey, data was collected for the originator brand and lowest-priced generic equivalent (i.e. generic product with the lowest price at each facility). Medicine prices were expressed as ratios relative to Management Sciences for Health international reference prices for 2009 (Median Price Ratio). Methods

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 overall 'basket' of medicines surveyed and for public, private and mission sectors. The availability data refers to the day of data collection at each particular facility and may not reflect average monthly or yearly availability of medicines at individual facilities. Using the salary of the lowest-paid unskilled government worker, affordability was calculated as the number of day’s wages this worker would need to purchase standard treatments (as recommended in the National Standard Treatment Guidelines, 6 th edition, 2010) for selected common conditions. Methods

Graph of Mean availability of medicines on the day of data collection, public, private and mission sectors Results

PUBLIC SECTOR PRICES Public sector procurement - ratio of median unit price to MSH international reference price (median price ratio or MPR) Public sector patient prices - ratio of median unit price to MSH international reference price (median price ratio or MPR) Results

Median MPRs for medicines found in both public procurement and public sector medicine outlets (final patient prices) PRIVATE SECTOR PATIENT PRICES Ratio of median unit price to MSH international reference price (median price ratio or MPR) Results

MISSION SECTOR PATIENT PRICES Ratio of median unit price to MSH international reference price(median price ratio or MPR), median for all medicines found Results

Number of day’s wages required to treat selected uncomplicated conditions based on standard treatments

Summary of Results- Public Sector Availability of medicines in the publi c – Mean availability of originator brand and generic medicines in the public sector was 2.7% and 19.3 %, respectively. Public sector procurement prices – In the public sector, the central medical store (CMS) is purchasing medicines at prices 1.43 times (at a MPR of 1.43) higher than international reference prices, indicating a reasonable level of purchasing efficiency. Pu blic sector patient prices – Final patient prices for generic medicines in the public sector are about three times higher than their international reference prices. – Public sector patient prices for generic medicines are % higher than those for public procurement, indicating the extent of mark- ups in the public sector distribution chain.

Summary of Results- Private Sector Availability in the Private Sector – the mean availability of originator brand and generic medicines was 9.0% and 17.4% for the private sector and 4.6% and 21.7% for the mission sector, respectively. Private sector patient prices: – Final patient prices for originator brands and lowest-priced generics in the private sector are about and 3.37 times their international reference prices, respectively. Affordability of standard treatment regimens: – In treating common conditions using a standard regimen, the lowest- paid government worker would need between 0.2 (diarrhoea), 0.6 (moderate pneumonia), and 1.3 (malaria) day’s wages to purchase lowest-priced generic medicines from the private sector.

Summary of Results- Mission Sector The results obtained from the Mission sector were not very different from those obtained in the public sector – Most of the mission sector facilities obtain their medicines from the public sector warehouses

Conclusions The survey results show that availability of child- specific medicines is very low across sectors in Ghana. While the availability of originator brand medicines is low in all sectors, when these are found in the private sector they cost over three times more than their generic equivalents. In public, private and mission sectors, even lowest- priced generics cost over three times their international reference price, on average.

Recommendations The national medicines selection process should be made child-medicines sensitive. These medicines should be listed on the national EML and on the NHIA reimbursement list to ensure subsequent procurement, distribution and reimbursement. The private wholesalers and distributors should also be engaged to procure child-specific medicines as part of their product lines. Thus the private sector supply chain can augment efforts in the public supply system. Prescribers and dispensers should be informed about available child-specific formulations to ensure the prescription and dispensing of appropriate formulations. There is existing opportunity within the DTC framework to support such action.

Research gap What factors contribute to low availability of child specific medicines in Ghana? – Medicines not listed on EML/NHIML – Profits – Interest of wholesalers – Local Manufacturer capability/capacity – Lack of availability on global markets

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