1. Prices of Antihypertensive Medicines in Sub-Saharan Africa (SSA) and Alignment to World Health Organization’s Model List Of Essential Medicines
Marc Twagirumukiza, MD, PhD Clinical Pharmacology Ghent University Ghent, Belgium

2. Focus on SSA 47 countries (+ South Sudan since June 2011)
Total population (2010): 800 Million
12.5% of the world population►1,2bn by 2025
Wars, conflicts and instability
Economy :
Only <10 % of global GDP (2008 est)
Farming for liverhood (75%) / Gender issues
GNI per capita: 858 US$
283 US$ in Burundi – US$ in Seychelles – WB, 2008 est
Life expectancy at birth : 50.5 years (36 in Zambia – 73 in Mauritius )

3. Inequality in health spending by region (WHO, 2000)

4. EXTERNAL AID AS PERCENTAGE OF TOTAL HEALTH SPENDING (2000)

5. SSA: Health and wealth, who pays?
Source: WHO, 2004

6. Mortality worldwide: CVDs are responsible for more than 30% of all deaths (WHO, 2005)
Global deaths by causes, 2005 HT
7.1
Mio
Those CVDs are a real health problem, world wide in terms of mortality but also in terms of morbidity
because they are responsable of more than.
For exemple for the year 2005, CVDs were responsible of more 30% of all deaths world wide. This diagram is showing global deaths by causes and you see that CVD were responsible of 17Mio death, including 7.1 Mio from only hypertension - which is the highest number of deaths.
and this figure is higher than the deaths by infectious and communicable diseases in the same year.
We have here HIV, TB etc
Moreover , as far as morbidity is concerned, there are estimated million hypertensive worldwide are (will rise to 1.6 billion people by 2025).
The 65% of those are in developing country.
Morbidity worldwide:
972 Mio hypertensive →will rise to 1.6 bn (2025)
65% in developing countries (including SSA).
P.Kearney, The Lancet, 2005
Source : WHO 2005: «Preventing Chronic Diseases: A Vital Investment»

7. HT in SSA Prevalence, Gender and burden
From population studies,
2008 in SSA: 74,7 million (38.3M; 36.4M) people with hypertension and prevalence of 16.2%
2025 in SSA: 125 million people with hypertension and a prevalence of 17.4%
How the problem of hypertension was documented?
A literature search was done for population studies conducted according the WHO STEPwise methodology, or similar published from January
1998 through December 2008.
 22 studies from 17 countries were analyzed.
 The prevalence and age-range specific prevalence was extracted, and standardized to the SSA 2008 and 2025 population. A logistic regression model
was performed on the standardized prevalence and overall age specific prevalence calculated, pooling together all studies.
 The number of hypertensives was estimated taking into account the number of adult inhabitants in rural and urban regions.
Twagirumukiza M, J Hypertens Jul;29(7):

8. Hypertension prevalence in Africa Vs Western countries
Twagirumukiza M, Journal of Hypertension 2007.

9. HT is a major Cardiovascular (CV) risk factor
Hypertension
coronary heart disease
peripheral artery disease
heart failure
Cerebro-vascular disease
We can consider hypertension as a disease but at the same time as a risk factor for other CVDs.
People with hypertension have a higher risk for heart disease and other medical problems than people with normal blood pressure.
The major cardiovascular disease linked to hypertension are coronary heart disease (like heart attack), cerebrovascular disease (stroke), peripheral artery disease (intermittent claudication), and heart failure. Thoses diseasea are called CVD
The hypertension is therefore considered both as a disease and as a risk factor for other CVDs.

10. Stroke mortality rate worldwide
Number of cases reaching hospitals are in last stage of complications – dying at home.

11. Stroke worldwide : DALYs lost
Disability Adjusted Life Years : The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.

12. Access-to-medicines worldwide
Documented worldwide: 1/3 of world’s population lacks regular access-to-essential medicines.
(Source: WHO/DAP 1998 )
Global response (1977): World Health Organization Essential Medicines List (WHO/EML): a limited range of medicines selected to meet better availability, better use of financial resources, and in that way greater access to care.
Many countries have developed their “National Essential Medicines Lists” (NEMLs) from WHO model.
Those NEMLs can play a role in standardization of the hypertension treatment in SSA.

13. Access-to-medicines Methods
Data on NEMLs and drug prices were collected from 65 public and 65 private pharmacies (from 13 SSA countries).
Benin
Burundi
Cameroon
Congo
DRC
Ivory Coast
Kenya
Mozambique
Niger
Rwanda
Senegal
Tanzania
Uganda
Data source:
Country’s Ministry of Health
National Pharmaceutical Office
Department of Medicines Policy and Standards (PSM) - Cluster of Health Technology and Pharmaceuticals of WHO (Geneva).

14. Antihypertensive medicines on WHO/EML
14-15th WHO/EML (2005, 2007)
Classes
Drug (ATC name)
Dosage
Duretics
Hydrochlorothiazide
25mg
β-blockers
Atenolol
50mg 100mg
ACE inhibitors
Enalapril
2.5mg
Calcium Channel blockers
Amlodipine
5mg
NEMLs
All investigated countries had a NEML, and all advocated drug classes were represented.

15. Overview of the situation NEMLs in sampled countries
Data on National Essential Medicine Lists (NEMLs) and drug prices were collected from 13 SSA countries.
All surveyed countries had a NEML but 38% were not updated in the last 5 years.
How the access – to tgreatment was analysed?
Essential Medicines List is a model list proposed by World Health Organization, includes a limited range of medicines.
These medicines are selected to meet better drug management, better use of financial resources, and in that way greater access to care.
…….

16. AMLO= Amlodipine, NIFE SL= Nifedipine sustained release.
Advocated drugs in SSA countries: % of NEMLs having advocated drugs on at least one of the WHO/EML 2002, 2003, 2005, 2007
HCTZ=Hydrochlorothiazide, ATEN=Atenolol, ENAL=Enalapril, CAPTO= Captopril,
AMLO= Amlodipine, NIFE SL= Nifedipine sustained release.

17. Non advocated drugs on NEMLs (Listed for HT Indications!)
Diuretics: Furosemide (10 NEMLs)
β-blockers: Propranolol (6 NEMLs), Labetalol, Carvedilol.
ACE inhibitors: Ramipril, Lisinopril.
CCBs: Nifedipine short acting (5 NEMLs), Verapamil, Diltiazem, Nicardipine.
Centrally acting drugs: Clonidine (5 NEMLs), Reserpine.

18. DDD prices adjusted to PPP per capita
Income adjusted price
This is a 3 axis diagram showing prices (on Y axis here), the different medicines on X axis here, and the countries on Z axis here.
The enelapril has the highist prices. And is somehow hidding the prices of other medicine because putting the scale very high. Lets’s remove analapril and see how other prices are.
Tropical Medicine and International Health, 2010; 15:

19. DDD prices adjusted to PPP per capita
High prices :
→Amlodipine
→Burundi & DRC
The same diagram without Enalapril shows that the Amlodipine is the most expensive, and prices are higher in some countries like DRC and Burundi
Tropical Medicine and International Health, 2010; 15:

20. Components of price build up along the chain
Manufacturer’s
Selling Price
Wholesaler margins
Retail margins
Import Tariffs
and other fees
Insurance+ Freight
Cost build up
Prashant Yadav, India, 2008

21. Price Components: Multi-country comparison Hidden costs of medicines
Items
Kenya
Rwanda
Tanzania
Nigeria
Manufacturer price  0
Import tariff
0 %
7 %
10 %
5 %
Port charges
8 %
1 %
Clearance and freight
2 %
4 %
Pre-shipment inspection
2,75 %  -
1,20 % - 
Pharmacy board fee
Importer's margins
30 %
25 %
9 %
22 %
VAT
18 %
Central government tax
State government tax
Wholesaler
11 %
3 %
Retail
20 %
50 %
Total mark up
72 %
81 %
77 %
107 %
Sources: Levison and Laing 2003, Governments files, MoH in every country

22. Discussions, remarks and study limitations:
The outlets surveyed were chosen in each country from the capital city and data from distanced rural areas could change according to transport add-ons.
The survey was limited to drugs on NEMLs which were on the WHO/EML between and 2007.
The present study ignored the price data from informal channels, such as street vendors, which should interact with the prices in SSA countries.

23. Discussions, remarks and study limitations:
Additionally, the present study is descriptive and not explanatory (no analysis of reasons of price disparities)
The prices discussed are prices for monotherapy whereas this does not necessarily reflect the cost of the management of hypertension since a patient with established hypertension requires more than one antihypertensive drug.
Apart from the price, the quality of medicines, not analysed here, is also of utmost importance in treatment. The major weakness of all medicines price comparisons is that they assume that all medicines on the market are of equal quality and therapeutic value.

24. Assumption model : Cost of hypertension treatment (estimates for SSA needs)

25. Conclusions
SSA sampled NEMLs are partially in compliance with WHO/EML.
Some still have less effective (Furosemide short acting) or dangerous drugs (Nifedipine immediate release formulation)
Prices of drugs advised by WHO/EML largely differ between drugs and for each drug within and between countries.
Adding advocated drugs on country's NEMLs nearly always contributes to reduce prices.
In general, hydrochlorothiazide is the cheapest drug and should be the drug to be considered first.

26. Treatment strategies
J Hum Hypertens Jan;25(1):

27. Thanks for your attention
Prices of Antihypertensive Medicines in Sub-Saharan Africa (SSA) and Alignment to World Health Organization’s Model List Of Essential Medicines
“Although the nature tries classifying people into richest and poorest, it is an ethical obligation for scholars and scientists to find how health care can reach everyone!”
Marc Twagirumukiza
Thanks for
your attention