Child-Specific Medicine Prices, Availability and ...

Better medicines for children in Ghana

Ministry of Health

GHANA

Child-Specific Medicine Prices, Availability and Affordability in Ghana

Report of a survey conducted September 2010

The Ghana National Drugs Programme (Ministry of Health)

P.O. Box MB 582, Accra‐Ghana

Tel +233 302 661670/1

Fax +233 302 664309

Email: [email protected]

Website: www.ghndp.org

Ghana Project Website: www.ghndp.org/childmedicines

WHO Project Website: www.who.int/childmedicines/en/

© World Health Organization 2011

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PROJECT TEAM

Survey manager

Brian Adu Asare, Ghana National Drugs Programme, Ministry of Health, Accra

Area supervisors

Ralph Johnson, Faculty of Pharmacy, Kwame Nkrumah University of Science and

Technology (KNUST), Kumasi

Joseph Tsiase, Ridge Hospital‐Pharmacy Department, Accra

Saviour Yevutsy, Pharmacy Unit, Ghana Health Service, Accra

Data collectors

Akosua Agyeman, Pharmacy Council, Accra

Maame Abena Kwane Owusu Ansah, Faculty Of Pharmacy, KNUST, Kumasi

Fidelicia Bakobie, Adabraka Polyclinic, Accra

Lina Bannerman‐Hyde, Faculty of Pharmacy, KNUST, Kumasi

Edmund Dianbiir, Regional Health Administration‐Upper West Region, Wa

Shelta Genfior, Pharmacy Council, Accra

R.K.S. Hadzi, Regional Health Administration‐Upper West Region, Wa

John Klu, Pharmacy Council, Accra

Wolarko Klu, Faculty of Pharmacy, KNUST, Kumasi

Cyril Dan Lardy, Maamobi Polyclinic, Accra

Sarah Quartey, Faculty of Pharmacy, KNUST, Kumasi

Zacchi Sabogu, Regional Health Administration‐Upper West Region, Wa

Data entry personnel

Karen Interkudzi, Pharmacy Council, Accra

Isaac Koduah, Independent Consultant, Accra

Report writing

Brian Adu Asare, Ghana National Drugs Programme, Ministry of Health

Edith Andrews Annan, WHO Country Office for Ghana, Accra

Martha Gyansa‐Lutterodt, Ministry of Health/Ghana Health Service, Accra

Administrative coordination

Augustina Koduah, Ghana National Drugs Programme, Ministry of Health


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TABLE OF CONTENTS

ABBREVIATIONS .............................................................................. ERROR! BOOKMARK NOT DEFINED.

LIST OF FIGURES AND TABLES............................................................................................................... II

ACKNOWLEDGEMENTS ......................................................................................................................... III

CONFLICT OF INTEREST STATEMENT ........................................................................................................... III

EXECUTIVE SUMMARY ............................................................................................................................ V

BACKGROUND ...................................................................................................................................... V METHODOLOGY .................................................................................................................................... V KEY RESULTS ...................................................................................................................................... VI

Availability of medicines in the public and private sector ................................................................... vi Public sector procurement prices .................................................................................................... vi Public sector patient prices ............................................................................................................ vi Private sector patient prices .......................................................................................................... vi Affordability of standard treatment regimens ................................................................................... vi

CONCLUSIONS .................................................................................................................................... VI RECOMMENDATIONS ............................................................................................................................ VII

INTRODUCTION ..................................................................................................................................... 1

OBJECTIVES ......................................................................................................................................... 2

COUNTRY BACKGROUND ........................................................................................................................ 2

HEALTH SECTOR ................................................................................................................................... 2 PHARMACEUTICAL SECTOR ....................................................................................................................... 3

METHODOLOGY ..................................................................................................................................... 5

OVERVIEW .......................................................................................................................................... 5 SELECTION OF MEDICINE OUTLETS .............................................................................................................. 5 SELECTION OF MEDICINES TO BE SURVEYED ................................................................................................... 6 DATA COLLECTION ................................................................................................................................. 6 DATA ENTRY ........................................................................................................................................ 7 DATA ANALYSIS .................................................................................................................................... 7

RESULTS .............................................................................................................................................. 8

1. AVAILABILITY OF MEDICINES ON THE DAY OF DATA COLLECTION ...................................................... 8

2. PUBLIC SECTOR PRICES ............................................................................................................... 11

3. PRIVATE SECTOR PATIENT PRICES ................................................................................................ 13

4. MISSION SECTOR PATIENT PRICES ............................................................................................... 14

5. COMPARISON OF PATIENT PRICES IN THE PUBLIC AND PRIVATE SECTORS ........................................ 14

6. AFFORDABILITY OF STANDARD TREATMENT REGIMENS ................................................................... 15

CONCLUSIONS AND RECOMMENDATIONS .............................................................................................. 18

REFERENCES ...................................................................................................................................... 20

ANNEX 1. LIST OF MEDICINES SURVEYED .............................................................................................. 21

ANNEX 2. MEDICINE DATA COLLECTION FORM ....................................................................................... 23

ANNEX 3. AVAILABILITY OF INDIVIDUAL MEDICINES, PUBLIC, PRIVATE AND MISSION SECTOR ................................................................................. 31

ANNEX 4. MEDIAN PRICE RATIOS, PUBLIC SECTOR PROCUREMENT PRICES ................................................ 33

ANNEX 5. MEDIAN PRICE RATIOS, PUBLIC SECTOR PATIENT PRICES ......................................................... 34

ANNEX 6. MEDIAN PRICE RATIOS, PRIVATE SECTOR PATIENT PRICES ....................................................... 37


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LIST OF FIGURES AND TABLES

Figure 1: Mean availability of child-specific medicines on the day of data collection; public, private, and mission sectors ..................................................................................................... 8

Figure 2: Median price ratios for selected child-specific medicines, originator brand and lowest-price generic equivalents, private sector ..................................................................................................... 14

Figure 3: Number of days’ wages required to treat selected uncomplicated conditions based on standard treatments ........................................................................................................................... 16

Table 1. Sample of public, private and mission sector medicine outlets ............................................................ 6

Table 2: Availability (%) of individual generic medicines by therapeutic class ................................................. 10

Table 3. Public sector procurement: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found ............................................................. 11

Table 4. Public sector patient prices: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found ............................................................. 12

Table 5. Median MPRs for medicines found in both public procurement and public sector medicine outlets (final patient prices) ........................................................................................................................... 12

Table 6. Ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found .......................................................................................................... 13

Table 8. Median MPRs for medicines found in both public and private sectors ................................................. 14

Table 9. Number of days' wages of the lowest-paid government worker needed to purchase standard treatments from the private sector .................................................................................................... 15

ABBREVIATIONS

CHPS Community‐based Health Planning and Services

DTC Drugs and Therapeutics Committee

EML Essential Medicines List

FDB Food and Drugs Board

GDP Gross domestic product

GNDP Ghana National Drugs Programme

HAI Health Action International

OB Originator brand

LPG Lowest‐priced generic equivalent

MPR Median price ratio

MSH Management Sciences for Health

NEML National Essential Medicines List

NHIS National Health Insurance Scheme

USD United States dollars (also $)

WHO World Health Organization


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ACKNOWLEDGEMENTS

We are grateful to the Ministry of Health of Ghana for permission to conduct this study. We

would like to thank the directors and heads of regional health directorates and heads of

private and mission health facilities and medicines outlets who endorsed the study and

granted access to facilities in the three survey areas.

We are thankful for the cooperation of pharmacists and other staff at the medicine outlets

where data collection took place.

We also wish to extend our thanks to the Better Medicines for Children (BMC) Ghana

Steering Committee Advisory Group.

Health Action International (HAI) and the World Health Organization (WHO) provided

technical support for the survey and their assistance is gratefully acknowledged. We would

also like to thank the following individuals whose assistance was invaluable:

Ms Alexandra Meagan Cameron

Dr Herman Garden

Dr Sue Hill

Dr Clive Ondari

This survey was conducted with financial support from WHO.

Conflict of interest statement

None of the authors of this report, nor anyone who had influence on the conduct, analysis or

interpretation of the results, has any competing financial or other interests.


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Page v

EXECUTIVE SUMMARY

Background

Reducing child mortality is one of the global priorities expressed in the Millennium

Development Goals (Goals 4 and 6). A pre‐condition to achieve these goals is the availability

of essential medicines for children. Mortality rates for infants and children under the age of

five are estimated at 50 and 80 per 1000 births, respectively. Most of these deaths are caused

by diseases that could be prevented, treated or managed by access to safe, essential child‐

specific medicines. Child‐specific medicines are those manufactured to suit the age, physical

condition and body weight of a child.

A field study to measure the price, availability and affordability of selected child‐specific

medicines was undertaken in Ghana from August to October 2010, using a standardized

methodology developed by the World Health Organization (WHO) and Health Action

International (HAI).

This survey had the following objectives:

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.

Methodology

The survey of medicine prices and availability was conducted in three regions, namely:

survey area 1 (Greater Accra Region); survey area 2 (Ashanti Region); and survey area 3

(Upper West Region). Data on 30 child‐specific medicines (38 formulations) were collected in

18 public and 42 private sector medicine outlets (including four mission drug outlets). The

tracer medicines list used in this assessment was based on WHO recommendations and local

country needs.

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 are expressed as ratios relative to Management Sciences for Health international

reference prices for 2009 (median price ratio, or MPR). Using the salary of the lowest‐paid

unskilled government worker, affordability was calculated as the number of days’ wages this

worker would need to purchase standard treatments (as recommended in the National

Standard Treatment Guidelines, 6th edition, 2010) for selected common conditions.


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Key results

Availability of medicines in the public and private sector

Mean availability of originator brand and generic medicines in the public sector was

2.7% and 19.3 %, respectively. However, 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.

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.

Public 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 101.9 % higher than those

bought at central procurement, indicating the extent of mark‐ups in the public sector

distribution chain.

Private sector patient prices

Final patient prices for originator brands and lowest‐priced generics in the private

sector are about 11.06 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) days’ wages to purchase lowest‐priced generic medicines from the

private sector.

Conclusions

The results of the survey show that child‐specific medicines are not readily available in

Ghana.


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Recommendations

Based on the above results, the following recommendations can be made for improving the

availability, price and affordability of medicines in Ghana:

In response to the low availability of child‐specific medicines in the health system,

there is a need to strengthen the national medicines selection process to include

essential medicines in the right formulations and strengths for children (i.e. child‐

specific medicines). These medicines will then be included in the national essential

medicines list (EML) and national health insurance scheme (NHIS) reimbursement

list to ensure subsequent procurement, distribution and reimbursement.

The private sector (local manufacturers) should be supported and actively engaged to

meet the demand for child‐specific medicines in Ghana.

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 appropriate prescription and dispensing. There is an existing

opportunity within the Drugs and Therapeutics Committee (DTC) framework to

support such action.


Page viii


Page 1

INTRODUCTION

The Better Medicines for Children (BMC) project was initiated by the World Health

Organization 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 in

priority countries by addressing availability, safety, efficacy and price.

The objectives of the project include:

promoting access to essential medicines for children, advocating for their inclusion in

national essential medicines lists, treatment guidelines and procurement schemes;

working with drug regulatory authorities to expedite regulatory assessment of

essential medicines for children;

developing measures to monitor and manage their prices.

Ghana embraced the BMC project in support of country efforts geared towards reducing

child mortality in line with the Millennium Development Goals (Goals 4 and 6), (UNDP,

2008).

Equitable access to essential medicines for children – and their rational use – are necessary

for achievement of national and global child mortality targets. Infant and under‐five

mortality rates in Ghana are estimated at 50 and 80 deaths respectively per 1000 births

(Ghana Statistical Service (GSS); Ghana Health Service and ICF Macro, 2009). Estimates from

2001 to 2006 show that Ghana’s under‐five mortality rate remains high, at 111 per 1000 live

births, (UNICEF, 2006).

Declines in child mortality that began in the 1980s have slowed. Between 1984 and 1998,

child mortality declined by 43/1000 live births. Between 1999 and 2006, child mortality

remained static. Newborn deaths – between birth and 28 days of life – are now an important

component of child mortality, representing 40% of all deaths (43/1000 live births in 2003)

(Ghana Statistical Service (GSS); Noguchi Memorial Institute of Medical Research (NMIMR);

and ORC Macro, 2004).

Mortality varies between geographic areas and is influenced by a number of factors

including the age and level of education of the mother, birth interval, rural or urban

residence and household income. Most deaths are preventable by access to safe, essential,

child‐specific medicines with the necessary framework for their rational use. Thus, the BMC

project seeks to increase access to child‐specific medicines within the framework of existing

policy.

From August to October 2010, the Ghana National Drugs Programme conducted a

nationwide study to document prices, availability and affordability of a selection of child‐

specific medicines in Ghana.


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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,

Affordability and Price Components (WHO/HAI, 2008), which is accessible on the HAI website

(World Health Organization and Health Action International, 2008).

OBJECTIVES

The main objectives of the study are to:

determine the availability of originator‐brand and generic versions of child‐specific

medicines in the public and private sectors;

assess the efficiency of purchasing child‐specific medicines in the public sector

compared with international reference prices;

determine the price of originator‐brand and generic medicines in the public and

private sectors, and compare them to international reference prices;

determine the difference in price of originator‐brand products and their generic

equivalents;

assess the affordability of treating common childhood illnesses.

COUNTRY BACKGROUND

Ghana is a relatively small country, covering an area of 238 537 km2, which is divided into 10

administrative regions. The population is 23.5 million (World Bank, 2009) with the majority

of Ghanaians living in rural areas (56.2%) (Ghana Statistical Service, 2009).

Ghana is a low‐income country with a Gross Domestic Product of US$ 647 per capita. About

30% of the population lives on less than US$1 per day, with 53.6% living on less than US$ 2

per day. Of the total labour force, approximately 11.2% is unemployed.

Health sector

In 2006, total per capita expenditure on health was US$ 33 (average exchange rate).

Approximately 5.1% of Ghana’s GDP is spent on health. The government’s total expenditure

on health is 34.2%, which represents 4.4% of all government expenditure. The remaining

65.8% of expenditure on health is private, of which 77.8% is out‐of‐pocket expenditure

through the national health insurance scheme (World Health Statistics, 2009).

The public health sector is composed of the following levels: tertiary/teaching hospitals;

regional hospitals; psychiatric/specialist hospitals; district hospitals; polyclinics; primary

health‐care centres/clinics; maternity homes; and community‐based health planning and

services (CHPS) compounds. The services offered at each level depend on the facility’s

capacity to manage diseases and all related medicines effectively at that level. Thus, the

national medicines selection process incorporates levels of care controls with integrated

triggers for referrals to higher levels of care.


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Approximately 55% of the population has health coverage through the national health

insurance scheme. The public health sector is complemented by the private sector,

comprising private medical and dental practitioners, private hospitals and clinics, and

mission‐based health facilities; these represent approximately 45% of total health services.

Pharmaceutical sector

There are approximately 8000 licensed, private retail medicine outlets in Ghana. A

substantial proportion of medicines is dispensed to patients by the public sector and the

private sector, including mission and private medical and dental practitioners.

National Medicines Policy

Ghana has an official National Medicines Policy (NMP) document. The 2004 National

Medicines Policy provides a framework for coordinating activities in the sector involving

public entities, private nongovernmental organizations (NGOs), donors, and other

stakeholders by specifying the goals and strategies for attaining them. The policy, however,

does not have an implementation plan or processes to achieve these strategies. There is a

need to review the existing document and make it implementable.

Regulatory system

Ghana has a medicines regulatory authority – the Food and Drugs Board (FDB) – which is

funded by the government and fees from the registration of medicines. Legal provisions

underpinning the board require transparency and accountability and promote a code of

conduct for its regulatory work. The FDB provides information on legislation, regulatory

procedures, prescribing information (such as indications, contraindications, side effects, etc.),

authorized companies and approved medicines.

Registration fees differ for originator brands and generic equivalents, and for imported and

locally produced medicines.

Ghana has a quality management system with a defined protocol for ensuring the quality of

medicines. Medicine samples are tested for the purposes of medicines registration and post‐

marketing surveillance. Regulatory procedures are in place for ensuring the quality of

imported medicines. There is, however, a need to strengthen the existing structures for the

sake of efficiency.

Legal provisions are in place for licensing prescribers and pharmacies.

Prescribing by generic name is obligatory in public sectors. The medicines policy allows for

generic substitution. As a result, there is no incentive to dispense generic medicines.

There are provisions in the medicines legislation and regulations covering promotion and

advertising of medicines.


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Medicines supply system

Public sector medicines procurement and distribution is the responsibility of the Ministry of

Health. Public sector procurement is pooled at the national level, but centralized at regional

level.

The following tender processes are used for public sector procurement: international

competitive bidding; national competitive bidding; and negotiation/direct purchasing

(including national shopping, sole sourcing and others). These are stated as percentage of

total cost.

National competitive tender 21% International competitive tender 37% National shopping 28% Sole sourcing 11% CMS/RMS/Others 3% Total 100%

(Ghana Ministry of Health‐Procurement Unit, 2006)

Public sector procurement is limited to medicines on the Essential Medicines List (EML).

Medicines financing

In 2007, total public expenditure for medicines was more than US$ 40.3 million. Ghana has a

policy of providing some medicines free of charge at primary care facilities in the public

sector to patients who cannot afford them, children, pregnant women and elderly people.

The following are true for Ghana with respect to medicines pricing:

Registration and consultation fees are commonly charged at primary care facilities.

Revenues from fees or the sale of medicines are never used to pay the salaries or

supplement the income of public health personnel in the same facility.

In Ghana, more than 50% of the population have public health insurance, which

covers selected essential medicines (National Health Insurance Authority, 2011).

Ghana does not have a national medicine price monitoring system. There are no

regulations requiring retail medicine pricing information to be made publicly

accessible.

Rational use of medicines

Ghana updated its National Essential Medicines List (NEML) in 2010. A committee is

responsible for the selection of medicines for the NEML, which is used for public sector

procurement.

The Ministry of Health, through the Ghana National Drugs Programme (GNDP), produces

national Standard Treatment Guidelines (STG) for major conditions. These were updated in

2010.


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Drug donations

There are official guidelines on medicine donations that provide regulations for donors and

provide guidance to the public, private, and/or NGO sectors on accepting and handling

donated medicines.

METHODOLOGY

Overview

A survey of prices, availability and affordability of child‐specific medicines in Ghana was

conducted using an adaptation of the standardized WHO/HAI methodology (World Health

Organization and Health Action International, 2008). Data on the availability and final

(client) prices of medicines were collected in medicine outlets in the public, private and

mission sectors. Government procurement prices were also surveyed.

Selection of medicine outlets

Sampling was conducted in a manner consistent with the WHO/HAI methodology, which

was modified in line with the BMC project methodology globally. This modified approach

has been shown, through a recent validation study, to yield a nationally representative

sample of medicine outlets (Madden, Meza, & Ewen, 2010).

Three regions were selected as survey areas for data collection. A combination of random

and purposive sampling methods was used. A major urban centre and two non‐urban areas

were selected. This resulted in the following three survey areas, which geographically

represent the southern, middle, and upper belts of Ghana:

1. Greater Accra Region (major urban centre, purposefully selected based on its unique

socio‐cultural and socio‐economic characteristics)

2. Ashanti Region

3. Upper West Region

In each survey area, the sample of public sector medicine outlets was identified by first

selecting the main public hospital. An additional four public medicine outlets (e.g. hospital

out‐patient medicine outlets, dispensaries) per survey area were then selected at random

from those within a four‐hour drive from the main hospital. In Ghana, this selection was

made from all public facilities expected to stock most of the medicines in the survey, namely

tertiary/secondary hospitals, district hospitals, and primary health‐care centres. Facilities that

were not expected to stock medicines due to their levels of care were excluded from the

sampling frame.

The public sector sample of 15 public outlets contained five public medicine outlets in each

of the three survey areas. The private sector sample was selected by identifying the private

sector medicine outlet closest to each of the selected public medicine outlets, yielding a total


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of 30 private outlets; these included five private hospitals, three private pharmacies and two

licensed chemical sellers. One mission hospital per survey area was selected for the mission

sector sample. In the Greater Accra Region however, an additional mission hospital was

added to yield adequate data for analysis.

Table 1. Sample of public, private and mission sector medicine outlets

Survey Area 1 (Greater Accra Region-

Southern)

Survey Area 2 (Ashanti Region –

Middle)

Survey Area 3 (Upper West Region –

Upper) Public sector - 1 tertiary hospital

- 2 district hospitals - 2 primary care centres

- 1 tertiary hospital - 2 district hospitals - 2 primary care centres

- 1 tertiary hospital - 2 district hospitals - 2 primary care centres

Private sector - 5 private hospital pharmacies - 3 pharmacies - 2 licensed drug stores

- 5 private hospital pharmacies - 3 pharmacies - 2 licensed drug stores

- 5 private hospital pharmacies - 3 pharmacies - 2 licensed drug stores

Mission sector - 2 mission hospital pharmacy

- 1 mission hospital pharmacy

- 1 mission hospital pharmacy

Total number of medicine outlets per survey area

17 16 16

Grand total = 49 outlets

Selection of medicines to be surveyed

A total of 30 (representing 38 formulations) medicines were surveyed – 31 formulations from

the WHO BMC core list and seven supplementary medicines selected at the country level.

For each medicine in the survey, up to two products were monitored, namely:

originator brand (OB) – the original patented pharmaceutical product;

lowest‐priced generic equivalent (LPG) – the lowest‐priced in the facility at the time

of the survey.

The methodology also includes the dosage form and strength that is to be collected for each

medicine. This ensures that data on comparable products are collected across facilities.

The full list of survey medicines is provided in Annex 1.

Data collection

The survey team consisted of a survey manager, three area supervisors, 12 data collectors,

and two data entry personnel. All personnel received training in the standard survey

methodology, and data collection and data entry procedures at a workshop held from 23‐25

August 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 over 13 days from 6‐18 September 2010. Data collectors visited

medicine outlets in pairs and collected information on medicine availability and pricing


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using a standard data collection form specific to the medicines being surveyed in Ghana (see

Annex 2). Area supervisors checked all forms at the end of each day, and validated the data

collection process by collecting data at 20% of the medicine outlets and comparing their

results 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 was collected on the prices that the government pays to procure

medicines. Data was collected for the same medicines as surveyed in medicine outlets.

Procurement data was obtained from recent procurement orders from Central Medical Stores

(CMSs).

Data entry

Survey data was entered into a pre‐programmed Microsoft™ 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

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 overall

list of surveyed medicines. The availability data only 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.

Medicine prices obtained during the survey are expressed as ratios relative to a standard set

of international reference prices:

Medicine Price Ratio (MPR) = median local unit price international reference unit price

The ratio is thus an expression of how much more or less the local medicine price is than the

international reference price; e.g. an MPR of 2 would mean that the local medicine price is

twice that of the international reference price. MPRs were only calculated for medicines with

price data from at least four medicine outlets, unless otherwise indicated. For procurement

prices, a single data point was accepted.

All prices were converted to US dollars using the exchange rate (buying rate) posted on 13

September 2010, the first day of data collection, i.e. US$ 1 = 1.43 GHC (Bank of Ghana, 2010).

The reference prices used in this survey were the 2009 Management Sciences for Health

(MSH) reference prices, taken from the International Drug Price Indicator Guide. They

represent actual procurement prices for medicines offered to low‐ and middle‐income

countries by non‐profit suppliers and international tender prices. These agencies typically

sell in bulk quantity to governments or large NGOs. They have relatively low procurement

prices that represent efficient bulk procurement without the costs of shipping or insurance.


Page 8

Price results are presented for individual medicines, as well as for the overall list of 38

medicines surveyed. Summary results for the list of medicines have been shown to provide a

reasonable representation of medicines in the country and price conditions on the market. As

averages can be skewed by outlying values, 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 observations, that is, the range between the 25th and 75th percentiles, is the

interquartile range.

Finally, the affordability of treating four common childhood conditions – pneumonia,

diarrhoea, worm infestation, and malaria – was assessed by comparing the total cost of

medicines prescribed at a standard dose, to the daily wage of the lowest‐paid unskilled

government worker (3.11 GHC/day and US$ 2.17 at the time of the survey). Although 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.

RESULTS

1. AVAILABILITY OF MEDICINES ON THE DAY OF DATA COLLECTION

Figure 1: Mean percentage availability of child-specific medicines on the day of data collection; public, private, and mission sectors


Page 9

Results show:

Average availability of all survey medicines in the public sector was low at 2.7 % for

originator brand products and 19.3% for generics (see Figure 1). When analysis is

limited to survey medicines listed on the NEML, public sector availability increases to

3.8% and 28.6% for originator brand products and generics, respectively.

Average availability in the private sector was low at 9.0% and 17.4% for branded and

generic products, respectively.

Average availability in the mission sector was also low at 4.6% and 21.7% for

originator brand and lowest‐price generic products, respectively. This was slightly

higher than the public sector, which recorded 2.7% and 19.3% for originator brand

products and lowest–price generics, respectively

Across sectors, the private sector had the highest relative availability of originator

brand products.

In all sectors, generics were the predominant product type available.

When availability is analysed by therapeutic class (see Table 2), it can be seen that oral‐

rehydration salts were available in 75% or more of the facilities in each of the public, private,

and mission sectors. However, zinc dispersible tablets were not found in any of the facilities

surveyed. Antibiotics had variable availability depending on the medicine and sector

surveyed. Amoxicillin suspension was the most frequently available antibiotic, with 100%

availability in both the public and private sectors. Conversely, amoxicillin dispersible tablet,

cotrimoxazole dispersible tablet, and gentamicin injection were not available in any of the

facilities surveyed. For antimalarials, quinine injection had reasonable availability in public

(80%) and mission (100%) facilities, while artemether‐lumefantrine dispersible tablet had low

availability (<10%) in these sectors, but higher availability in the private sector (46.7%).

Artesunate/amodiaquine dispersible tablet had low availability (<10%) in all three sectors.

For anti‐asthmatics, salbutamol was available in about one third, one quarter, and half of

facilities in the public, private, and mission sectors, respectively, while beclometasone was

not found at all.


Page 10

Table 2: Availability of individual generic medicines by therapeutic class

Therapeutic group

Medicine name Public sector (n-15)

%

Private sector (n-30)

%

Mission sector (n-4)

% Antianaemia Ferrous salt, suspension 0 3.3 0

Antiasmetics Beclomelasone, inhaler 0 0 0

Antiasmetics Salbutamol, inhaler 33.3 26.7 50

Antibiotics Amoxicillin, dispersible tablet 0 0 0

Antibiotics Amoxicillin/clavulanic acid, suspension 0 0 0

Antibiotics Cotrimaxazole, dispersible tablet 0 0 0

Antibiotics Gentamycin, injection 0 0 0

Antibiotics Procaine penicillin, injection 0 0 0

Antibiotics Amoxicillin clavulanic acid, suspension 6.7 6.7 0

Antibiotics Amoxicillin/clavulanic acid, dispersible tablet

6.7 10 0

Antibiotics Ceftriazone, injection 33.3 23.3 50

Antibiotics Azithromycin, powder 10 50 75

Antibiotics Chloramphenicol, injection 46.7 23.3 25

Antibiotics Benzylpenicillin, injection 73.3 56.7 75

Antibiotics Amoxicillin, suspension 100 100 75

Antiepileptic Carbamazepine, chewable tablet 0 0 0

Antiepileptic Carbamazepine, suspension 0 0 0

Antiepileptic Diazepam, rectal solution 0 0 0

Antiepileptic Phenytoin, chewable 0 0 0

Antiepileptic Phenytoin, suspension 0 0 0

Antiepileptic Phenobarbital, oral liquid 6.7 0 0

Antiepileptic Carbarmazepine, tablet 6.7 30 25

Antiepileptic Phenobarbital, injection 20 13.3 25

Antimalarial Artesunate/amodiaquine, dispersible tablet

0 6.7 0

Antimalarial Artemether+lumefantrine, dispersible tablet

6.7 46.7 0

Antimalarial Quinine, injection 80 36.7 100

Antituberculosis Isoniazid, scored tablet 0 3.3 0

Intestinal anthelminthics

Mebendazole, tablet 46.7 23.3 50

Medicines used in diarrhoea

Zinc, dispersible tablet 0 0 0


Oral rehydration solution (ORS), sachet

0 1 25


Oral rehydration solution (ORS), sachet

80 86.7 75

NSAIDS Paracetamol, suspension 0 13.3 0

NSAIDS Ibuprofen, tablet 86.7 76.7 100

Opiods analgelsics Morphine, immediate release tablet 0 3.3 0

Opiods analgelsics Morphine, oral solution 6.7 0 0

Vitamins Vitamin A, capsules 0 3.3 0

Vitamins Vitamin K1, injection-water soluble 53.3 10 75


Page 11

Annex 3 contains the availability of individual medicines in the public, private and mission

sectors.

In the public sector, medicines that were not found at any facilities (0% availability) were:

amoxicillin dispersible tablet, amoxicillin/clavulanic, acid suspension, artesunate/

amodiaquine dispersible tablet, beclometasone inhaler, carbamazepine chewable tablet,

carbamazepine suspension, cotrimoxazole dispersible tablet, diazepam rectal solution,

gentamycin injection, isoniazid scored tablet, morphine immediate release tablet, phenytoin

chewable, phenytoin suspension, ferrous salt suspension, paracetamol suspension, procaine

penicillin injection, vitamin A capsules, and zinc dispersible tablet.

Medicines that were not found at any facilities in the private or mission sectors were:

amoxicillin dispersible tablet, amoxicillin/clavulanic acid suspension, beclometasone inhaler,

cotrimoxazole dispersible tablet, diazepam rectal solution, gentamycin injection,

carbamazepine suspension and chewable tablet, phenytoin suspension and chewable tablet,

morphine oral solution, phenobarbital oral liquid and zinc dispersible tablet.

2. PUBLIC SECTOR PRICES

2.1 Public sector procurement prices

Table 3. Public sector procurement: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found

Product type Median MPR 25th percentile 75th percentile Originator brand

(n = 0 medicines) 0 0 0

Lowest-price generic (n = 8 medicines) 1.43 1.12 2.54

Of the 38 medicines included in the survey, no originator brands and eight generics were

found in the public procurement sector. Based on the median MPRs, the public sector is

procuring generics at 1.43 times their international reference prices. Thus, the government

procurement agency is purchasing with moderate efficiency. The interquartile range shows

moderate variation in MPRs across individual medicines. Further investigation is required to

identify the determinants of these variations in purchasing efficiency.

Annex 4 contains procurement prices for individual medicines. Generic medicines being

purchased at prices significantly less than international prices include benzylpenicillin

injection (MPR = 0.46) and carbamazepine tablets (MPR = 0.49). Conversely, medicines for

which the government is paying several times the international reference price include

mebendazole tablets (MPR = 2.51), oral‐rehydration solution (ORS) sachet (MPR = 3.33), and

phenobarbital injection (MPR = 2.64).


Page 12

2.2 Public sector patient prices

Table 4. Public sector patient prices: ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found


(n = 1 medicine)* 2.06 2.06 2.06


The results above show that in the public sector:

One originator brand medicine (artemether‐lumefantrine dispersible tablet) was

found with sufficient price data to enable calculation of the MPR. This medicine was

being sold at an estimated 2.06 times its international reference price.

Lowest‐price generic medicines are generally sold at 3.35 times their international

reference price. Half of the lowest‐price generic medicines were priced at 2.30 (25th

percentile) to 4.19 (75th percentile) times their international reference price. There is

therefore moderate variation in MPRs across individual generic medicines.

Annex 5 contains the MPRs for individual medicines found in the public sector for which

one or more price points were found.

Originator brand medicines priced several times higher than international reference prices

include mebendazole tablet (MPR = 131.12), ceftriaxone injection (MPR = 17.50),

azithromycin powder (MPR = 9.99) and salbutamol inhaler (MPR = 4.42). The 25th and 75th

percentiles for individual medicines show that for originator brands, prices vary significantly

between public sector medicine outlets. Lowest‐price generic medicines priced several times

higher than international reference prices include mebendazole tablet (MPR = 52.45),

carbamazepine tablet (MPR = 10.23), ceftriaxone injection (MPR = 5.02), and ORS sachet

(MPR = 4.28). The 25th and 75th percentiles for individual medicines show that for generic

medicines, prices vary significantly between public sector medicine outlets.

2.3 Comparison of patient prices and procurement prices in the public sector

Table 5. Median MPRs for medicines found in both public procurement and public sector medicine outlets (final patient prices)

Product type Median MPR Public Procurement

Median MPR Public Patient Prices

% difference patient prices to procurement

Lowest-price generic (n = 8 medicines) 1.43 2.89 101.9%

Only those medicines found in both public procurement and public sector medicine outlets

were included in the analysis for Table 5 to allow for the comparison of purchase price to

final patient price. Results show that final patient prices in the public sector are 101.9%

higher than procurement prices for generic equivalents. These price differences may result


Page 13

from local purchases at public health facilities and/or from add‐on costs applied in the

distribution chain.

3. PRIVATE SECTOR PATIENT PRICES

Table 6. Ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found


(n = 8 medicines) 11.06 3.68 19.75


Table 6 shows that in the private sector:

Originator brand medicines are generally sold at 11.06 times their international

reference price. Half of the originator brand medicines were priced at 3.68 (25th

percentile) to 19.75 (75th percentile) times their international reference price; there is

therefore substantial variation in MPRs across individual originator brand medicines.


reference price. Half of the lowest‐priced generic medicines were priced at 2.28 (25th


therefore moderate variation in MPRs across individual generic medicines.

Annex 6 contains the median price ratios for individual medicines found in the private sector

for which one or more price points were found. Originator brand medicines priced several

times higher than international reference prices include mebendazole tablet (MPR = 131.12),

ceftriaxone injection (MPR=28.09), azithromycin powder (MPR=16.97), carbamazepine tablet

(MPR = 12.79), and amoxicillin suspension (MPR = 9.32). The 25th and 75th percentiles for

individual medicines show that, for originator brands, prices vary significantly between

private sector medicines outlets. Lowest‐price generic medicines priced several times higher

than international reference prices include mebendazole tablet (MPR = 21.85), morphine

immediate release tablet (MPR=9.11), phenobarbital injection (MPR = 7.65), vitamin A

capsules (MPR = 7.36), procaine penicillin injection (MPR = 6.48) and ceftriaxone injection

(MPR = 5.64). The 25th and 75th percentiles for individual medicines show that, for generic

medicines, prices vary significantly between private sector medicines outlets.

Figure 2 suggests that the price for a ceftriaxone injection is 28.1, 5.6 times the international

reference price; while the price for artemether+lumefantrine dispersible tablet is 2.1 and 1.2

times the international reference price for originator branded and lowest‐price generics,

respectively.

The difference in MPR for originator brand and lowest price generics across the five selected

medicines in Figure 2 is noteworthy. Whiles the originator brand‐lowest price generic MPR

difference is relatively small, that for azithromycin and ceftriaxone is huge. This

phenomenon can be due to the impact of medicines affordability initiatives e.g. Affordable

Medicines for Malaria Initiative, or it may need further investigation.


Page 14

Figure 2: Median price ratios for selected child-specific medicines, originator brand and lowest-price generic equivalents, private sector

4. MISSION SECTOR PATIENT PRICES

Table 7. Ratio of median unit price to MSH international reference price (median price ratio or MPR), median for all medicines found


(n = 3 medicines) 0 0 0

Lowest price generic (n = 14 medicines) 3.39 3.04 3.75

Table 7 shows that in the mission sector:


reference price. Half of the lowest‐priced generic medicines were priced at 3.04 (25th


therefore only a small variation in MPRs across individual generic medicines.

5. COMPARISON OF PATIENT PRICES IN THE PUBLIC AND PRIVATE SECTORS

Table 8. Median MPRs for medicines found in both public and private sectors

Product type Median MPR

Public sector patient prices

Median MPR Private sector patient

prices

% difference private to public

Originator brand (n = 5 medicines) 9.99 16.97 69.8%

Lowest-price generic (n = 16 medicines) 2.46 3.37 37.0%

*To enable comparison of a greater number of products, medicines with a minimum of one price point were included in the analysis, compared to the four price points usually required.


Page 15

Only those medicines found in both public and private sector medicine outlets were

included in the analysis (Table 8) to allow for comparison of prices between the two sectors.

Results show that final patient prices in the private sector are 69.8% and 37.0% higher than in

the public sector for originator brands and generic equivalents, respectively. Given that

overall availability of medicines in the public sector is low, patients are paying substantially

higher prices to purchase medicines from the private sector.

6. AFFORDABILITY OF STANDARD TREATMENT REGIMENS

The affordability of treatment for four common conditions was estimated as the number of

daysʹ wages of the lowest‐paid, unskilled government worker needed to purchase medicines

prescribed at a standard dose. For all the conditions, treatment duration was defined as a full

course of therapy as specified in the Ghana Standard Treatment Guidelines 6th Edition (2010).

The daily wage of the lowest‐paid unskilled government worker used in the analysis was

3.11 GHC.

Table 9. Number of days' wages of the lowest-paid government worker needed to purchase standard treatments from the private sector

Condition Drug name, strength,

dosage form ***

Age Group

STG ** Total # of Units per

Treatment

Median price for Lowest- priced

generic product in the private

Sector (GHS)

Median Treatment Price (GHS)

Based on lowest price

generic products

Pneumonia Amoxicillin 125 mg/5 ml

Child 1-5 years

First-line treatment: Amoxicillin oral 250 mg 8 hourly for 7 days

2 bottles (200 ml)

0.0145/ml 2. 9 0.9 days

Diarrhoea ORS sachet Child 2-10 years

First-line: ORS 500 ml or more as necessary

2 sachets 0.3000 /sachet

0.60 0.19 days

Worm infestation

Mebendazole 500 mg

Child > 12 months

First-line : Mebendazole 500 mg as single dose

1 tablet 0.5000 /tablet

0.50 0.16 days

Malaria Artesunate +amodiaquine, dispersible tablet 25 mg+ 75 mg

Child 1-6 years

Treatment of choice: AA Day 1: 2 tablets (50 mg+150 mg) Day 2: 2 tablets (50 mg+150 mg) Day 3:2 tablets (50 mg+150 mg)

6 tablets 0.5250* /tablet

3.15 1.01 days

Malaria Artemether +lumefantrine dispersible tablet 20 mg +120 mg

Child 3-8 years

Alternative treatment: Day 1: 2+2 tablets Day 2: 2+2 tablets Day 3: 2+2 tablets

12 tablets 0.3333* /tablet

4.00 1.29 days

* Less than four data points have been used to compute this aggregate value. ** (Ministry of Health, Ghana National Drugs Programme, 2010) *** (Ministry of Health, Ghana National Drugs Programme, 2010)


Page 16

Figure 3: Number of days’ wages required to treat selected uncomplicated conditions based on standard treatments

The affordability of lowest‐price generics in the public sector was reasonable for the

conditions in Figure 3, with standard treatment costing less than, or just over, a day’s wage.

However, given the low availability of medicines in the public sector, many patients are

forced to purchase medicines from the private sector; therefore the high number of days’

wages required is of concern, especially for the treatment of malaria in children.

It should be noted that treatment costs refer to medicines only and do not include the

additional costs of consultation and diagnostic tests. Further, many people in Ghana earn

less than the lowest government wage. As such, even treatments that 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 costs.

Discussion

The results indicate that in the public sector, the procurement of child‐specific medicines is

moderately efficient, as shown by purchase prices reasonably higher than international

reference prices. As a result of add‐on costs in the public sector distribution chain, by the

time these medicines are sold to patients prices have increased by 101.9%. Based on the

tracer medicines list, the public sector is purchasing only generic products, which is in line

with the national drug policy.

Availability of generic child medicines in the public sector is poor. The average availability

was around 20% in all sectors, while in the public sector the availability of medicines on the


Page 17

national EML (Ministry of Health, Ghana National Drugs Programme, 2010) was higher at

28.6%.

In the public sector, medicines that were not found at any facilities (0% availability)

were amoxicillin dispersible tablet, amoxicillin/clavulanic acid suspension,

artesunate/amodiaquine bispersible tablet, beclometasone inhaler, carbamazepine chewable

tablet, carbamazepine suspension, cotrimoxazole dispersible tablet, diazepam rectal solution,

gentamycin injection, isoniazid scored tablet, morphine immediate release tablet, phenytoin

chewable, phenytoin suspension, ferrous salt suspension, paracetamol suspension, procaine

penicillin injection, vitamin A capsules and yinc dispersible tablet.

Given the low availability of medicines in the public sector, it can be concluded that many

patients must purchase medicines from the private sector, which also experiences low

availability.

Originator brand medicines are rarely available in the public sector; however, this is only an

issue where high‐quality generics are not available.

In the private sector, generic equivalents were the predominant product type found. Mean

availability in the private sector was 17.4% for lowest‐price generic medicines and 9.0 % for

originator brands. Medicines that were not found at any facilities in the private sector were

amoxicillin dispersible tablet, amoxicillin/clavulanic acid suspension, beclometasone inhaler,

cotrimoxazole dispersible tablet, diazepam rectal solution, gentamycin injection,

carbamazepine suspension and chewable tablet, phenytoin suspension and chewable tablet,

morphine oral solution, phenobarbital oral liquid and zinc dispersible tablet.

Final patient prices for lowest‐price generic medicines in the public, private and mission

sectors were consistent at over three times the international reference price, which is

somewhat high. Compared with the public sector, private sector patient prices were, on

average, 37% higher for generic equivalents. These results show that patients are paying

substantially more for medicines in the private sector than in the public sector. Given the

relatively low availability in the public sector, this is a cause for concern.

Medicines were not priced consistently with respect to their international reference price. In

the public sector, half of lowest‐price generic medicines were priced between 2.30 and 4.19

times their international reference price. In the private sector, half of lowest‐price generic

medicines were priced between 2.28 and 4.59 times their international reference price, while

half of originator brand medicines were priced between 3.68 and 19.75 times their

international reference price. These disparities suggest substantial variation in procurement

efficiency and price mark‐ups between medicines.

The interquartile range for the median price ratios of individual medicines shows the

variability in the medicine price across medicine outlets. The results show a product‐type‐

dependent variation in price across outlets within the private and public sectors. There is a

wider interquartile range for originator brand products compared to generics. The high


Page 18

degree of variability observed between outlets is likely the result of low market competition

and/or the absence of price regulations.

The affordability of lowest‐price generics was fair for diarrhoea and pneumonia for children

under five years with standard treatment costing less than a day’s wage. The treatment of

uncomplicated diarrhoea in children aged two to 10 years (0.2 day’s wage) is reasonable,

while that of uncomplicated pneumonia in children one to five years (0.9 day’s wage) is

relatively higher. The cost of treatment of malaria with artemether‐lumefantrine is somewhat

high (1.3 days’ wage). Considering that artemether‐lumefatrine is first‐line therapy for

malaria in Ghana, this needs further investigation in view of the global trend for reducing

the cost of malaria treatment. The development of complications and cost of treatment of an

entire family may have the potential of burdening parents and the NHIA.

It should be noted that many people in Ghana earn much less that the lowest government

wage. Given that 30% of the population is living below the international poverty line of less

than $1/day, even treatments that appear affordable are too costly for the poorest people.

Further studies and comparisons between high‐ and low‐income countries can also provide

an evidence base for equity or differential pricing strategies by multinational manufacturers,

whereby low‐income countries pay less than wealthier countries for essential medicines.

The results of this medicine price survey provide insight into the availability, price and

affordability of medicines in Ghana. 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.

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 MPRs is

dependent on the number of supplier prices used to determine the median MSH

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, MPR

results 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.

CONCLUSIONS AND RECOMMENDATIONS

Conclusions

The survey results show that the availability of child‐specific medicines is very low across

sectors of Ghana. In public, private and mission sectors, even lowest‐priced generics cost on

average over three times their international reference price. While the availability of


Page 19

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.

Recommendations

In response to the general low availability of child‐specific medicines in Ghana’s

health sector, 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 for their product lines. In this way 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 an existing opportunity within the DTC framework to support such action.


Page 20

REFERENCES

1. Bank of Ghana (2010). Accessed 6 September 2010 from www.bog.gov.gh.

2. Ghana Ministry of Health – Procurement Unit (2006). 2006 Procurement Data, MOH/PU.

3. Ghana Statistical Service, Ghana Health Service and ICF Macro (2009). Ghana Demographic

and Health Survey, 2008. Accra: GSS, GHS and ICF Macro.

4. Ghana Statistical Service (2009). Key Social, Economic and Demographic Indicators. Accessed

13 December 2010, from http://statsghana.gov.gh/KeySocial.html

5. Ghana Statistical Service (GSS), Noguchi Memorial Institute of Medical Research

(NMIMR), and ORC Macro (2004). Ghana Demographic and Health Survey 2003. Calverton,

Maryland: GSS, NMIMR and ORC Macro.

6. Madden, JM, Meza E, and Ewen M (2010). Measuring medicine prices in Peru: validation of

key aspects of WHO/HAI survey methodology. Rev Panam Salud Publica.

7. Ministry of Health, Ghana National Drugs Programme (2010). Essential Medicines List

(EML), Accra, Yamens Press.

8. Ministry of Health, Ghana National Drugs Programme (2010). Standard Treatment

Guidelines (STG). Accra, Yamens Press.

9. National Health Insurance Authority, (2011). Summary Statistics and Exempt Groups.

Accessed December 2011 from www.nhis.gov.gh/?CategoryID=309

10. UNDP (2008). Millenium Development Goals. United Nations Development Programme.

11. UNICEF (2006). Multiple Indicator Cluster Survey 2006. United Nations Childrenʹs Fund.

12. World Bank (2009). World Development Indicators. Accessed in 2011 from

http://data.worldbank.org/data‐catalog/world‐development‐indicators

13. World Health Organization and Health Action International (2008). Measuring Medicine

Prices, Availability, Affordability and Price Components. Accessed 8 August, 2011 from

http://www.haiweb.org/medicineprices

14. World Health Statistics (2009). Table7: Health Expenditures. World Health Organization.


Page 21

ANNEX 1. LIST OF MEDICINES SURVEYED

List* No. Medicine Name (Name must be unique)

Medicine Strength Dosage Form

C 1. Amoxicillin clavulanic acid, suspension 125 mg/5 ml /ml C 2. Amoxicillin, dispersible tablet 250 mg /tablet C 3. Amoxicillin, suspension 250 mg+ 62.5 mg /ml C 4. Amoxicillin/clavulanic acid, dispersible tablet 250 mg + 125 mg /tablet S 5. Amoxicillin/clavulanic acid, suspension 125 mg+31.25 mg/5ml /ml C 6. Artemether + Lumefantrine, dispersible tablet 20 mg + 120 mg /tablet S 7. Artesunate/Amodiaquine, dispersible tablet 25 mg+ 75 mg /tablet S 8. Azithromycin, powder 200 mg/5 ml /ml C 9. Beclometasone, inhaler 100 mcg/dose /dose C 10. Benzylpenicillin, injection 600mg = 1 million IU /vial C 11. Carbamazepine, chewable tablet 100 mg /tab C 12. Carbamazepine, suspension 100 mg/5 ml /ml S 13. Carbamazepine, tablet 200 mg /pack C 14. Ceftriaxone, injection 500 mg vial /vial C 15. Chloramphenicol, injection 1 gram vial /vial C 16. Cotrimoxazole, dispersible tablet 100 mg + 20 mg (also expressed as

400 mg + 80 mg) /tablet

C 17. Diazepam, rectal solution 2.5 mg/ml /ml C 18. Ferrous salt, suspension 30 mg Fe/5ml /ml C 19. Gentamycin, injection 10 mg/ml /ml C 20. Ibuprofen*, tablet 200 mg /tablet C 21. Isoniazid, scored tablet 50 mg /tablet S 22. Mebendazole, tablet 500 mg /tablet C 23. Morphine, immediate release tablet 10 mg /tablet C 24. Morphine, oral solution 10 mg/5 ml /ml C 25. Oral rehydration solution (ORS), sachet 500 ml /sachet C 26. Oral rehydration solution (ORS), Sachet To make 1 litre /sachet C 27. Paracetamol, suspension 120 mg/ 5ml OR 125 mg/5 ml /ml C 28. Phenobarbital, injection 200 mg/ml /ml C 29. Phenobarbital, oral liquid 3 mg/ml (also expressed as 15 mg/5

ml) /ml

C 30. Phenytoin, chewable tablet 50 mg /tab C 31. Phenytoin, suspension 25 or 30 mg/1ml /ml C 32. Procaine penicillin, injection 1 gram = 1 million IU /vial S 33. Quinine, injection 300 mg/ml /ml C 34. Salbutamol, inhaler 100 mcg/dose /dose C 35. Spacer device C 36. Vitamin A, capsules 100 000IU /tablet S 37. Vitamin K1, injection (water soluble) 1 mg /ml C 38. Zinc, dispersible tablet 20 mg /tablet

* C = Core or recommended by WHO, S = Supplementary or selected nationally


Page 22


Page 23

ANNEX 2. MEDICINE DATA COLLECTION FORM

A B C D E F G H I J

Medicine name, dosage form, strength

Medicine type Brand or product name(s)

Manufacturer

Available today "yes(1)" or "no

(0)"

Target pack size (pack size

recommended)

Pack size

found

Price of pack found

Unit price (4 digits)

Comments

1. Amoxicillin, suspension 125mg/5ml

Highest-priced Amoxil GSK 100 ml /ml

Lowest-priced 100 ml /ml

2. Amoxicillin, dispersible tablet 250 mg

Highest-priced Amoxil GSK 21 /tablet

Lowest-priced 21 /tablet

3. Amoxicillin clavulanic acid, suspension 250 mg+ 62.5 mg

Highest-priced Augmentin GSK 100 ml /ml


4. Amoxicillin/clavulanic acid, suspension 125 mg+31.25 mg/5ml

Highest-priced Augmentin GSK 100 ml /ml


5. Amoxicillin/clavulanic acid, dispersible tablet 250 mg + 125 mg

Highest-priced Augmentin GSK 21 /tablet



Page 24

A B C D E F G H I J



Manufacturer


(0)"


recommended)

Pack size

found

Price of pack found


Comments

6. Artemether + lumefantrine, dispersible tablet, 20 mg + 120 mg

Highest-priced Coartem Novartis 6 x 1 /tablet

Lowest-priced 6 x 1 /tablet

7. Artesunate/ amodiaquine, dispersible tablet 25 mg+ 75 mg

Highest-priced 3 /tablet


8. Azithromycin, powder 200 mg/5 ml

Highest-priced Zithromax Pfizer 30 ml & 60 ml /ml

Lowest-priced 30ml & 60ml /ml

9. Beclometasone, inhaler 100 mcg/dose

Highest-priced Becotide GSK 1 inhaler (200 doses)

/dose

Lowest-priced 1 inhaler (200 doses)

/dose

10. Benzylpenicillin, injection 600 mg = 1 million IU

Highest-priced Crystapen Britannia 1 vial /vial

Lowest-priced 1 vial /vial

11. Carbamazepine suspension,

Highest-priced Tegretol Novartis 100ml /ml


Page 25

A B C D E F G H I J



Manufacturer


(0)"


recommended)

Pack size

found

Price of pack found


Comments

100 mg/5ml Lowest-priced 100ml /ml

12. Carbamazepine, chewable tablet 100 mg

Highest-priced Tegretol Novartis 20 /tablet


13. Carbamazepine, tablet 200 mg

Highest-priced Tegretol Novartis 100/pack /pack

Lowest-priced 100/pack /pack

14. Ceftriaxone, injection 500 mg vial

Highest-priced Rocephin Roche 1 vial /vial


15. Chloramphenicol, Injection 1 g vial

Highest-priced Chloromycetin

Pfizer 1 vial /vial


16. Cotrimoxazole, dispersible tablet, 100 mg + 20 mg (also expressed as 400 mg + 80 mg)

Highest-priced Septrin Roche 15 /tablet



Page 26

A B C D E F G H I J



Manufacturer


(0)"


recommended)

Pack size

found

Price of pack found


Comments

17. Diazepam, rectal solution 2.5 mg/ml

Highest-priced Valium Roche 0.5 ml /ml

Lowest-priced 0.5 ml /ml

18. Ferrous salt, suspension 30 mg Fe/5 ml

Highest-priced 200 ml /ml


19. Gentamycin, injection 10 mg/ml

Highest-priced Garamycin/Cidomycin

Schering Plough

2-ml ampoule /ml

Lowest-priced 2-ml ampoule /ml

20. Ibuprofen*, tablet 200 mg

Highest-priced Brufen Abbott 24 /tablet


21. Isoniazid, scored tablet 50 mg

Highest-priced Rimoton Roche 56 /tablet



Page 27

A B C D E F G H I J



Manufacturer


(0)"


recommended)

Pack size

found

Price of pack found


Comments

22. Mebendazole, tablet 500 mg

Highest-priced Vermox Jansen-Cilag

1 /tablet


23. Morphine, oral solution 10mg/5ml

Highest-priced Oramorph Boehringer 100 ml /ml


24. Morphine, immediate release tablet 10 mg

Highest-priced Sevredol Napp 56 /tab

Lowest-priced 56 /tab

25. Oral rehydration solution (ORS), sachet To make 500 ml

Highest-priced Dioralyte Sianofi-Aventis

1 sachet /sachet

Lowest-priced 1 sachet /sachet

26. Oral rehydration solution (ORS), sachet To make 1 litre

Highest-priced Dioralyte Sianofi-Aventis

1 sachet /sachet

Lowest-priced 1 sachet /sachet


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Manufacturer


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recommended)

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found

Price of pack found


Comments

27. Paracetamol, suspension 120 mg/5 ml OR 125 mg/5 ml

Highest-priced Panadol GSK 100 ml /ml


28. Phenobarbital, injection 200 mg/ml

Highest-priced Luminal Bayer 1 ml/ampoule /ml

Lowest-priced 1 ml/ampoule /ml

29. Phenobarbital, oral liquid 3 mg/ml (also expressed as 15 mg/5ml)



30. Phenytoin, suspension 25 or 30 mg/5ml

Highest-priced Epanutin Pfizer 500 ml /ml


31. Phenytoin, chewable tablet 50 mg

Highest-priced Epanutin Pfizer 90 /tablet



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Manufacturer


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recommended)

Pack size

found

Price of pack found


Comments

32. Procaine penicillin, injection 1 g = 1 million IU

Highest-priced 1 vial /vial


33. Quinine, injection 300 mg/ml



34. Salbutamol, inhaler 100 mcg/dose

Highest-priced Ventolin GSK 1 inhaler (200 doses)

/dose

Lowest-priced 1 inhaler (200 doses)

/dose

35. Spacer device -

36. Vitamin A, capsules 100 000 IU


Lowest-priced 50 /tab

37. Vitamin K1, injection (water soluble) 1 mg

Highest-priced Konakion Roche 10 ml /ml



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A B C D E F G H I J



Manufacturer


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recommended)

Pack size

found

Price of pack found


Comments

38. Zinc, dispersible tablet 20 mg




ANNEX 3. AVAILABILITY OF INDIVIDUAL MEDICINES, PUBLIC, PRIVATE AND MISSION SECTOR

Medicines Availability in Outlets

Brand Lowest Price Medicine Name Medicine List National

EML Status

Public (n=15)

%

Private (n=30)

%

Mission (n=4)

%

Public (n=15)

%

Private (n=30)

%

Mission (n=4)

% 1. Amoxicillin clavulanic

acid, suspension Global Yes 0 0 0 6.7 6.7 0

2. Amoxicillin, dispersible tablet

Global No 0 0 0 0 0 0

3. Amoxicillin, suspension Global Yes 0 16.7 0 100 100 75

4. Amoxicillin/clavulanic acid, dispersible tablet

Supplementary No 0 3.3 0 6.7 10 0

5. Amoxicillin/clavulanic acid, suspension

Global Yes 0 0 0 0 0 0

6. Artemether + Lumefantrine, dispersible tablet

Global Yes 33.3 50 75 6.7 46.7 0

7. Artesunate/Amodiaquine, dispersible tablet

Supplementary Yes 0 0 0 0 6.7 0

8. Azithromycin, powder Supplementary Yes 13.3 36.7 25 40 50 75

9. Beclometasone, inhaler Global Yes 0 0 0 0 0 0

10. Benzylpenicillin, injection Global Yes 0 0 0 73.3 56.7 75

11. Carbamazepine, chewable tablet

Global No 0 3.3 0 0 0 0

12. Carbamazepine, suspension

Global No 0 16.7 0 0 0 0

13. Carbamazepine, tablet Supplementary Yes 0 23.3 0 6.7 20 25

14. Ceftriaxone, injection Global No 13.3 16.7 0 33.3 23.3 50

15. Chloramphenicol, injection

Global Yes 0 0 0 46.7 23.3 25

16. Cotrimoxazole, dispersible tablet

Global No 0 0 0 0 0 0

17. Diazepam, rectal solution Global Yes 0 0 0 0 0 0

18. Ferrous salt, suspension Global Yes 0 0 0 0 3.3 0

19. Gentamycin, injection Global No 0 0 0 0 0 0

20. Ibuprofen*, tablet Global Yes 0 0 0 86.7 76.7 100

21. Isoniazid, scored tablet Global No 0 0 0 0 3.3 0

22. Mebendazole, tablet Supplementary Yes 6.7 53.3 25 46.7 23.3 50

23. Morphine, immediate release tablet

Global Yes 0 0 0 0 3.3 0


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Medicines Availability in Outlets

Brand Lowest Price Medicine Name Medicine List National

EML Status

Public (n=15)

%

Private (n=30)

%

Mission (n=4)

%

Public (n=15)

%

Private (n=30)

%

Mission (n=4)

% 24. Morphine, oral solution Global no 0 0 0 6.7 0 0

25. Oral rehydration solution (ORS), sachet

Global yes 0 0 0 80 86.7 75

26. Oral rehydration solution (ORS), sachet

Global yes 0 0 0 0 10 25

27. Paracetamol, suspension Global yes 0 0 0 0 13.3 0

28. Phenobarbital, injection Global yes 0 0 0 20 13.3 25

29. Phenobarbital, oral liquid Global no 0 0 0 6.7 0 0

30. Phenytoin, chewable tablet

Global no 0 0 0 0 0 0

31. Phenytoin, suspension Global no 0 6.7 0 0 0 0

32. Procaine penicillin, injection

Global yes 0 0 0 0 6.7 0

33. Quinine, injection Supplementary yes 0 0 0 80 36.7 100

34. Salbutamol, inhaler Global yes 6.7 16.7 0 33.3 26.7 50

35. Spacer device Global no 0 0 0 0 0 0

36. Vitamin A, capsules Global yes 0 0 0 0 3.3 0

37. Vitamin K1, injection (water soluble)

Supplementary yes 0 0 0 53.3 10 75

38. Zinc, dispersible tablet Global no 0 0 0 0 0 0


Page 33

ANNEX 4. MEDIAN PRICE RATIOS, PUBLIC SECTOR PROCUREMENT PRICES

Medicine Name Medicine list MPR – Central Procurement

1 Amoxicillin clavulanic acid, suspension Global

2 Amoxicillin, dispersible tablet Global

3 Amoxicillin, suspension Global 1.40

4 Amoxicillin/clavulanic acid, dispersible tablet Supplementary

5 Amoxicillin/clavulanic acid, suspension Global

6 Artemether + Lumefantrine, dispersible tablet Global

7 Artesunate/Amodiaquine, dispersible tablet Supplementary

8 Azithromycin, powder Supplementary

9 Beclometasone, inhaler Global

10 Benzylpenicillin, injection, Global 0.46

11 Carbamazepine, chewable tablet Global

12 Carbamazepine, suspension Global

13 Carbamazepine, tablet Supplementary 0.49

14 Ceftriaxone, injection Global

15 Chloramphenicol, injection Global

16 Cotrimoxazole, dispersible tablet Global

17 Diazepam, rectal solution Global

18 Ferrous salt, suspension Global

19 Gentamycin, injection Global

20 Ibuprofen*, tablet Global 1.33

21 Isoniazid, scored tablet Global

22 Mebendazole, tablet Supplementary 2.51

23 Morphine, immediate release tablet Global

24 Morphine, oral solution Global

25 Oral rehydration solution (ORS), sachet Global 3.33

26 Oral rehydration solution (ORS), sachet Global

27 Paracetamol, suspension Global

28 Phenobarbital, injection Global 2.64

29 Phenobarbital, oral liquid Global

30 Phenytoin, chewable tablet Global

31 Phenytoin, suspension Global

32 Procaine penicillin, injection Global

33 Quinine, injection Supplementary

34 Salbutamol, inhaler Global

35 Spacer device Global

36 Vitamin A, capsules Global

37 Vitamin K1, injection (water soluble) Supplementary 1.46

38 Zinc, dispersible tablet Global


Page 34

ANNEX 5. MEDIAN PRICE RATIOS, PUBLIC SECTOR PATIENT PRICES

No. Medicine Name Medicine

Type

Median Price Ratio (MPR)

25th percentile

75 th percentile

1 Amoxicillin clavulanic acid, suspension Brand

1 Amoxicillin clavulanic acid, suspension Lowest price 0.96 0.96 0.96

2 Amoxicillin, dispersible tablet Brand

2 Amoxicillin, dispersible tablet Lowest price

3 Amoxicillin, suspension Brand

3 Amoxicillin, suspension Lowest price 2.18 2.18 2.18

4 Amoxicillin/clavulanic acid, dispersible tablet Brand

4 Amoxicillin/clavulanic acid, dispersible tablet Lowest price 0.24 0.24 0.24

5 Amoxicillin/clavulanic acid, suspension Brand

5 Amoxicillin/clavulanic acid, suspension Lowest price

6 Artemether + Lumefantrine, dispersible tablet Brand 2.06 1.76 2.14

6 Artemether + Lumefantrine, dispersible tablet Lowest price 0.59 0.59 0.59

7 Artesunate/Amodiaquine, dispersible tablet Brand

7 Artesunate/Amodiaquine, dispersible tablet Lowest price

8 Azithromycin, powder Brand 9.99 7.49 12.49

8 Azithromycin, powder Lowest price 3.98 2.61 4.64

9 Beclometasone, inhaler Brand

9 Beclometasone, inhaler Lowest price

10 Benzylpenicillin, injection Brand

10 Benzylpenicillin, injection Lowest price 2.43 2.43 2.43

11 Carbamazepine, chewable tablet Branp

11 Carbamazepine, chewable tablet Lowest price

12 Carbamazepine, suspension Brand

12 Carbamazepine, suspension Lowest price

13 Carbamazepine, tablet Brand

13 Carbamazepine, tablet Lowest price 10.23 10.23 10.23

14 Ceftriaxone, injection Brand 17.50 14.96 20.03

14 Ceftriaxone, injection Lowest price 5.02 5.02 5.02

15 Chloramphenicol, injection Brand

15 Chloramphenicol, injection Lowest price 1.36 1.17 1.36

16 Cotrimoxazole, dispersible tablet Brand

16 Cotrimoxazole, dispersible tablet Lowest price

17 Diazepam, rectal solution Brand

17 Diazepam, rectal solution Lowest price


Page 35


Type


25th percentile

75 th percentile

18 Ferrous salt, suspension Brand

18 Ferrous salt, suspension Lowest price

19 Gentamycin, injection Brand

19 Gentamycin, injection Lowest price

20 Ibuprofen*, tablet Brand

20 Ibuprofen* tablet Lowest price 1.34 1.34 1.34

21 Isoniazid, scored tablet Brand

21 Isoniazid, scored tablet Lowest price

22 Mebendazole, tablet Brand 131.12 131.12 131.12

22 Mebendazole, tablet Lowest price 52.45 52.45 52.45

23 Morphine, immediate release tablet Brand

23 Morphine, immediate release tablet Lowest price

24 Morphine, oral solution Brand

24 Morphine, oral solution Lowest price

25 Oral rehydration solution (ORS), sachet Brand

25 Oral rehydration solution (ORS), sachet Lowest price 4.28 4.28 4.28

26 Oral rehydration solution (ORS), sachet Brand 3.44 3.44 3.44

26 Oral rehydration solution (ORS), sachet Lowest price

27 Paracetamol, suspension Brand

27 Paracetamol, suspension Lowest price

28 Phenobarbital, injection Brand

28 Phenobarbital, injection Lowest price 1.27 1.27 1.27

29 Phenobarbital, oral liquid Brand

29 Phenobarbital, oral liquid Lowest price

30 Phenytoin, chewable tablet Brand

30 Phenytoin chewable tablet Lowest price

31 Phenytoin, suspension Brand

31 Phenytoin, suspension Lowest price

32 Procaine penicillin, injection Brand

32 Procaine penicillin, injection Lowest price

33 Quinine, injection Brand

33 Quinine, injection Lowest price 4.10 4.10 4.10

34 Salbutamol, inhaler Brand 4.42 4.42 4.42

34 Salbutamol, inhaler Lowest price 2.50 2.50 2.50

35 Spacer device Brand

35 Spacer device Lowest price


Page 36


Type


25th percentile

75 th percentile

36 Vitamin A, capsules Brand

36 Vitamin A, capsules Lowest price

37 Vitamin K1, injection (water soluble) Brand

37 Vitamin K1, injection (water soluble) Lowest price 3.35 3.35 5.70

38 Zinc, dispersible tablet Brand

38 Zinc, dispersible tablet Lowest price Note: the number of outlets that must have the medicine to qualify for inclusion was set to one (1) to generate this table. Thus repeated values for median, 25th percentile and 75th percentile indicate the availability of the product in only one outlet.


Page 37

ANNEX 6. MEDIAN PRICE RATIOS, PRIVATE SECTOR PATIENT PRICES


Type

Median Price Ratio (MPR) 25%ile 75%ile

1 Amoxicillin clavulanic acid, suspension Brand 1 Amoxicillin clavulanic acid, suspension Lowest price 1.33 1.31 1.35 2 Amoxicillin, dispersible tablet Brand 2 Amoxicillin, dispersible tablet Lowest price 3 Amoxicillin, suspension Brand 9.32 8.86 9.32 3 Amoxicillin, suspension Lowest price 2.25 1.96 2.56 4 Amoxicillin/clavulanic acid, dispersible tablet Brand 0.68 0.68 0.68 4 Amoxicillin/clavulanic acid, dispersible tablet Lowest price 0.31 0.27 0.34 5 Amoxicillin/clavulanic acid, suspension Brand 5 Amoxicillin/clavulanic acid, suspension Lowest price 6 Artemether + Lumefantrine, dispersible tablet Brand 2.06 1.76 2.13 6 Artemether + Lumefantrine, dispersible tablet Lowest price 1.18 0.88 1.69 7 Artesunate/Amodiaquine, dipersible tablet Brand 7 Artesunate/Amodiaquine, dispersible tablet Lowest price 1.03 0.73 1.33 8 Azithromycin, powder Brand 16.97 16.65 18.61 8 Azithromycin, powder Lowest Price 2.37 2.20 4.19 9 Beclometasone, inhaler Brand 9 Beclometasone, inhaler Lowest price

10 Benzylpenicillin, injection Brand 10 Benzylpenicillin, injection Lowest price 3.24 2.43 4.05 11 Carbamazepine, chewable tablet Brand 1.50 1.50 1.50 11 Carbamazepine, chewable tablet Lowest price 12 Carbamazepine, suspension Brand 1.98 1.62 2.01 12 Carbamazepine, suspension Lowest price 13 Carbamazepine, tablet Brand 12.79 10.66 15.37 13 Carbamazepine, tablet Lowest Price 4.69 4.26 6.08 14 Ceftriaxone, injection Brand 28.09 24.83 31.35 14 Ceftriaxone, injection Lowest price 5.64 3.64 6.52 15 Chloramphenicol, injection Brand 15 Chloramphenicol, injection Lowest price 1.94 1.46 2.43 16 Cotrimoxazole, dispersible tablet Brand 16 Cotrimoxazole, dispersible tablet Lowest price 17 Diazepam, rectal solution Brand 17 Diazepam, rectal solution Lowest price 18 Ferrous salt, suspension Brand 18 Ferrous salt, suspension Lowest price 19 Gentamycin, injection Brand 19 Gentamycin, injection Lowest price 20 Ibuprofen*, tablet Brand 20 Ibuprofen*, tablet Lowest price 2.69 1.34 3.36 21 Isoniazid, scored tablet Brand


Page 38


Type

Median Price Ratio (MPR) 25%ile 75%ile

21 Isoniazid, scored tablet Lowest price 22 Mebendazole, tablet Brand 131.12 131.12 135.60 22 Mebendazole, tablet Lowest price 21.85 8.74 32.78 23 Morphine, immediate release tablet Brand 23 Morphine, immediate release tablet Lowest price 9.11 9.11 9.11 24 Morphine, oral solution Brand 24 Morphine, oral solution Lowest price 25 Oral rehydration solution (ORS), sachet Brand 25 Oral rehydration solution (ORS), sachet Lowest price 4.28 4.28 5.35 26 Oral rehydration solution (ORS), sachet Brand 26 Oral rehydration solution (ORS), sachet Lowest price 1.72 1.72 3.01 27 Paracetamol, suspension Branp 27 Paracetamol, suspension Lowest price 1.97 1.77 2.29 28 Phenobarbital, injection Brand 28 Phenobarbital, injection Lowest price 7.65 5.10 9.56 29 Phenobarbital, oral liquid Brand 29 Phenobarbital, oral liquid Lowest price 30 Phenytoin, chewable tablet Brand 30 Phenytoin, chewable tablet Lowest price 31 Phenytoin, suspension Brand 0.34 0.34 0.34 31 Phenytoin, suspension Lowest price 32 Procaine penicillin, injection Brand 32 Procaine penicillin, injection Lowest price 6.48 6.34 6.63 33 Quinine, injection Brand 4.10 3.80 4.10 33 Quinine, injection Lowest price 4.10 3.48 6.15 34 Salbutamol, inhaler Brand 4.23 3.46 4.23 34 Salbutamol, inhaler Lowest price 3.51 3.03 3.84 35 Spacer device Brand 35 Spacer device Lowest price 36 Vitamin A, capsules Brand 36 Vitamin A, capsules Lowest price 7.36 7.36 7.36 37 Vitamin K1, injection (water soluble) Brand 37 Vitamin K1, injection (water soluble) Lowest price 3.75 3.55 5.23 38 Zinc, dispersible tablet Brand 38 Zinc, dispersible tablet Lowest price

Note: the number of outlets that must have the medicine to qualify for inclusion was set to one (1) to generate this table. Thus repeated values for median, 25th percentile and 75th percentile indicate the availability of the product in only one outlet.

Child-Specific Medicine Prices, Availability and ...

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