Background: Children in resource-limited countries are more likely to die from treatable conditions than those in higher resource settings due to a lack of the right essential medicine at the right time. Globally millions of children die every year from conditions that could be treatable with existing medicines before they reach their fifth birthday. This study aimed in assessing the availability and affordability of essential medicine for children in selected health facilities of southern nations, nationalities, and peoples' regions (SNNPR), Ethiopia. Method: A medicine outlets-based cross-sectional study was conducted to assess the availability, affordability, and prices of the 30 selected essential medicines (EMs) for children in 30 public and 30 private medicine outlets in SNNPR from March 29 to May 5, 2019, applying WHO and Health Action International (HAI) tools. Availability was expressed as the percentage of sampled medicine outlets per sector that the surveyed medicine was found on the day of data collection. The amount of daily wages required for the lowest-paid government unskilled worker (LPGW) to buy one standard treatment of an acute condition or treatment for a chronic condition for a month was used to measure affordability and median price ratio for the price of EMs. The results: Availability varied by sector, type of medication, and level of health facilities. The average availability of EM was 57.67% for the public sector and 53.67% for the private sector. Ceftriaxone, SOR, zinc sulfate, and cotrimoxazole were the most widely available types of medications in the two sectors. The median price ratios (MPR) for the cheapest drugs LP were 1.26 and 2.24 times higher than their International Reference Price (IRP) in the public and private sectors respectively. Eighty-two percent of LP medicines in the public and 91 % of LP medicines in the private sectors used in the treatments of prevalent common conditions in the region were unaffordable as they cost a day's or more wages for the LPGW. Conclusion: Availability, affordability, and price are determinant pre-requisite for EMs access. According to the current work, although fair availability was achieved, the observed high price affected affordability and hence access to EMs.
Keywords: Essential medicine; Children; Availability; Affordability; Price; SNNPR; Ethiopia
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1186/s12889-021-10745-5.
A high standard of health is a basic right for every human [[
However, access to EMs is challenging; especially for children. Some of the factors which impaired children's access to EMs were lack of suitable dosage forms, the high price of medicines, inefficient government procurement culture, extreme mark-ups in the distribution chain, and exaggerated taxes and duties being applied to these medicines [[
Thus, millions of children die every day before they reach their fifth birthday, of conditions that could be treatable with existing EMs globally. Of newborn deaths, 22% are due to infections such as pneumonia, diarrhea, and malaria. Childhood pneumonia and diarrhea are the most important causes of childhood mortality and account for about 30% of all child deaths worldwide [[
Access to EMs can be determined by availability, affordability, accessibility, acceptability, accommodation/adequacy, and/or quality of the medicines [[
A series of initiatives have been taken by Ethiopia to improve access to EMs. A three-tier health-delivery service system was introduced to address accessibility issue. The primary level consisting of health posts (HPs), health centers and primary hospitals are made accessible to the majority of population to provide promotion, preventive and curative services; general hospitals provide secondary level services; and specialized hospitals provide tertiary services [[
To eliminate an interrupted drug supply, drug price variation and promote the availability, pharmaceuticals fund and supply agency (PFSA) under Proclamation No. 553/2007 based on the pharmaceuticals logistics master plan (PLMP) was established [[
Despite these initiatives, the country is still confronted with low access to children's EMs. In a study conducted in South-west Ethiopia, 55.65% of EMs were available, and considerable price variation among studied sectors impeded access to EMs [[
A medicine outlets-based cross-sectional descriptive study was conducted in the SNNP region, South Ethiopia. Quantitative data was collected adapting price and availability format prepared by WHO/HAI 'make medicine child-size project' from March 29 to May 5, 2019 (Supplementary Annex II) [[
Out of 13 administrative zones found in the region, choosing Hawasa, the capital city of the SNNP region as a center for the study, six administrative zones that can be reached within 1 day were randomly selected [[
Twenty-three EMs were taken based on proposed formulations and strength for key tracer children medicines WHO EMLc core list as specified by the 'Better Medicines for Children Project' [[
Six data collectors were trained as per WHO/HAI methodology to do the collection task. The pre-test was undertaken in Werabe town where the trainees were trained. Being supervised and controlled for quality of data daily by Principal Investigators, 60 medicine outlets were visited to collect data on the availability and patient prices of medicines. The availability of medicine was addressed by interviewing the staff working at the facility and physically checking the study medicines for their presence as stated in the dispensing area [[
Table 1 List of medicine surveyed in Southern Ethiopia
S.No. Name of Medicine Strength Dosage Form Indication 1. Amoxicillin 125 mg/ml Suspension Infectious disease 2. Amoxicillin 250 mg Dispersible tab Infectious disease 3. Amoxicillin+Clavulanic acid 125 + 31.25 mg/5 ml Suspension Infectious disease 4. Amoxicillin+Clavulanic acid 125 mg + 31.25 mg Dispersible tab Infectious disease 5. Ampicillin 500 mg Injection Infectious disease 6. Artemether +Lumefantrine 20 mg + 120 mg Tablet Malaria 7. Artesunate 60 mg Injection Malaria 8. Beclomethasone inhaler 100mcg/dose Inhaler Asthma 9. Benzylpenicillin 1MIU Powder Infectious disease 10. Carbamazepine 100 mg/5 ml Suspension Seizure disorder 11. Ceftriaxone injection 1 g Powder Severe infection 12 Chloramphenicol injection 1 g Powder Infectious disease 13. Cloxacillin 125 mg/5 ml Suspension Infectious disease 14. Cotrimoxazole (Sulphamethoxazole + Trimethoprim) 200 mg + 40 mg/5 ml Suspension Pneumonia 15. Diazepam l injection 5 mg/ml Solution Seizure disorder 16. Ferrous salt 30 mg Fe/5 ml Suspension Anemia 17. Gentamycin 40 mg/ml Injection Infectious disease 18. Ibuprofen 100 mg/5 ml Syrup Pain/inflammation 19. Isoniazide 100 mg Tablet TB 20. Morphine 10 mg/5 ml Oral Solution 21. Oral Rehydration Solution 1 litter Powder Dehydration 22. Paracetamol 120 mg/5 ml Syrup Pain 23. Paracetamol 125 mg Suppository Pain 24. Penicillin G, Benzathine penicillin 1.2MIU Injection Infectious disease 25. Phenobarbitone 30 mg Syrup Seizure disorder 26. Phenytoin 50 mg Suspension Seizure disorder 27. Procaine penicillin injection 1 MIU Powder Infectious disease 28. Salbutamol Puff 100mcg/dose Inhaler Asthma 29. Vitamin A 100,000 IU Capsule Xerophthalmia 30 Zinc sulfate 20 mg Tablet Dehydration
MIU Million international unit, IU International unit, TB Tuberculosis, mcg Micrograms
The availability of individual medicine was measured by the physical presence of them in the medicine outlets during data collections [[
IRP was used for comparing the prices of the 17 lowest-priced medicines [[
Graph
The local unit price was obtained by dividing the retail price per pack by the pack size. The supplier medicine prices obtained from the MSH drug price guide 2015 were taken as the IRPs for core medicines (Supplementary Annex III) [[
Affordability was estimated by comparing the total price required to cover the complete course of standard treatment for prevalent diseases in the region (Supplementary Annex IV) (SNNP Regional Health bureau) with the number of daily wages of the LPGW, which was 28.57 ETB per day (0.99 USD) during data collection (Ethiopian ministry of finance and economics salary scale for the public sector) [[
Availability was varied by type of medicine, sectors, and level of health facilities. Ceftriaxone, ORS, zink sulfate, and cotrimoxazole were available in more than 90% of medicine outlets. On the other hand, none of the sectors stocked beclomethasone inhaler, morphine 10 mg syrup, and carbamazepine 100 mg syrup while isoniazid 100 mg tablet and vitamin A capsules being stocked by public sectors. The availability of nine studied medicines was less than 50%. Public sectors hold the lowest-priced medicines, unlike private sectors which had both the lowest and highest priced medicines (see Table 2).
Table 2 Average availability of individual children essential medicines in the public and private sectors
Name of medicine, strength, dosage form Percentage of outlets where medicine found Public Sector ( Private Sector ( LP LP HP Amoxicillin 250 mg Dispersible tablet 53.33 13.33 0 Amoxicillin 125 mg/5 ml Suspension 86.67 93.3 6.67 Amoxicillin + Clavulinc acid 125 mg + 31.25 mg Dispersible tablet 6.67 6.67 0 Amoxicillin + Clavulanic acid 125 mg + 31.25 mg/5 ml Suspension 66.67 86.67 20 Ampicillin 500 mg Powder for Injection 73.33 70 0 Artemether + Lumefantrine 20 mg + 120 mg Dispersible Tab 76.67 83.33 0 Artesunate 60 mg powder for Injection 30 10 0 Benzylpenicillin 1 MIU Powder for Injection 56.67 26.67 0 Beclomethasone 100mcg/dose inhaler 0 0 0 Carbamazepine 100 mg/5 ml Suspension 0 0 0 Ceftriaxone 1 g Powder for Injection 90 100 23.33 Chloramphenicol 1 g Powder for Injection 13.33 6.67 0 Cloxacillin 125 mg/5 ml Suspension 66.67 60 0 Cotrimoxazole (Sulphamethoxazole + Trimethoprim) 100 mg + 20 mg Suspension 86.67 100 3.33 Diazepam 5 mg/ml Injection 76.67 76.67 0 Ferrous salt 30 mg/5 ml Suspension 66.67 83.33 6.67 Gentamycin 40 mg/ml Injection 86.67 73.33 0 Ibuprofen 100 mg/5 ml Syrup 73.33 86.67 0 Isonaized 100 mg Tablet 76.67 0 0 Morphine 10 mg/5 ml Oral Solution 0 0 0 Oral Rehydration Solution Powder to make 1 l 90 100 3.33 Paracetamol 120 mg/5 ml Syrup 73.33 86.67 6.67 Paracetamol 125 mg Suppository 70 93.33 23.33 Penicillin G, Benzanthine n 1.2MIU for Injection 76.67 73.33 0 Phenobarbitone 30 mg Tablet 60 36.67 0 Phenytoin 50 mg Tablet 46.67 40 0 Procaine penicillin 1 MIU Powder for Injection 26.67 13.33 0 Salbutamol puff 100mcg/dose Inhaler 66.67 96.67 3.33 Vitamin A 100,000 IU Capsule 43.33 0 0 Zinc sulfate 20 mg Tablet 90 93.33 0
MIU Million international unit, IU International unit, LP Lowest-priced, HP Highest-priced
The average availability for lowest-priced medicines in the public and private sectors were 57.67 and 53.67% respectively. The highest-priced medicines' average availability in private sectors was found to be 3.87%. When the level of health facility for medicine availability was considered, private pharmacies lead both sectors having 71.6% followed by General Hospitals, 68.39% (Table 3).
Table 3 Availability of children essential medicine per study area, sector, and level of health facility in Southern Ethiopia
Study Area Average Availability of Medicines Public Sector ( Private Sector ( Public Sector ( 57.67 Gurage Zone 60.00 64.44 0.74 1.General Hospital 68.39 Hadiya Zone 58.62 62.22 0.74 2.Primary Hospital 58.62 Halaba Zone 61.38 65.19 6.67 3. Health Center 57.28 Hawasa City 63.45 66.67 2.22 Private Sector ( 53.67 Kembata-Tembaro Zone 59.31 60.74 4.44 4. Pharmacy 71.60 Wolaita Zone 62.07 64.44 4.44 5. Drug Store 62.04
LP Lowest-priced, HP Highest-priced
Of 27 EMs, 22 which were found in ≥4 public drug outlets sold 1.56 times their IRPs. The MPRs of 11 EMs were higher than 1.5. Free of charge, artesunate 60 mg, coartem 120 mg, isoniazid 100 mg, and vitamin A 100,000 IU were given. There were 23 EMs purchased 2.60 times their IRPs in the private sectors. Pursuant to Gelders S. et al, 14 EMs had ≤2.5 MPRs [[
To estimate the price variation of individual medicines across sectors, the MPR of the 17 LP medicines was determined. Thus, in the public and private sectors, the MPR (25th -75th percentile) was 1.26 and 2.24, respectively. For these EMs, the average lowest-priced (LP) MPR in the public sectors was 1.57 and private sectors 2.54. Of the 17 LP medicines, 11 EMs in the public sector had an MPR ≤ 1.5, indicating that patient prices were appropriate. In the public sector, the most expensive drug marketed at 3.23 times its IRP was the phenobarbitone 30 mg tablet. Only 3 EMs in the private sector had an LP MPR ≥ 2.5, suggesting that they were expensive in the study area relative to the IRPs. Paracetamol 125 mg suppository (MPR = 5.21), the most costly drug in the private sector, was found to be the cheapest in the public sector. (Table 4). In general, with caution, patients in the study region charged appropriate prices for 53 and 59% of 17 EMs in the public and private sectors, respectively.
Table 4 Median Price Ratio (the 25th–75th Percentile) of Lowest and Highest Priced Medicines (n = 17)
List of medicine available in At least four Medicine outlets Public LP MPR Private LP MPR Amoxicillin 125 mg/5 ml suspension 1.78(1.6–2.28) 2.27(2.23–2.51) Amoxicillin + Clavulinc acid 156.25 suspension 1.10(0.83–2.17) 2.52(2.33–2.59) Ampicillin 500 mg powder for injection 1.85(1.16–2.09) 3.01(2.5–3.31) Ceftriaxone 1 g powder for injection 1.69(1.32–1.86) 2.29(2.17–2.42) Cloxacillin 125 mg/5 ml suspension 1.04(0.58–1.06) 1.17(0.92–1.29) Cotrimoxazole 240 mg/5 ml suspension. 1.26(1.17–1.68) 2.09(1.72–1.26) Diazepam 5 mg/ml injection 1.37(1.03–1.54) 1.65(1.36–1.97) Ferrous sulfate 30 mg /5 ml 1.02(0.28–1.04) 1.09(0.29–1.3) Gentamycin 40 mg/ml injection. 1.24(0.74–1.46) 1.75(1.13–2.04) Ibuprofen 100 mg/5 ml syrup 2.36(1.99–2.68) 3.15(2.68–3.43) ORS to make 1 L 0.95(0.72–2.06) 3.67(2.45–4.12) Paracetamol 125 mg suppository 0.65(0.64–0.74) 5.21(3.82–6.79) Paracetamol 120 mg/5 ml syrup 1.51(0.94–1.95) 2.24(1.80–3.23) Penicillin G,Benzthine 1.2MIU 1.99(1.49–2.5) 2.78(2.5–3.23) Phenobarbitone 30 mg tablet 3.23(2.71–3.55) 3.78(2.89–4.85) Phenytoin 50 mg tablet 1.10(0.5–1.2) 1.19(0.75–2.28) Salbutamol puff 100mcg/dose inhaler 1.69(1.22–1.83) 1.92(1.83–2.47)
LP lowest-priced, HP highest-priced, MPR median price ratio, ORS Oral rehydration salt
Assuming all wages go for drug purchasing, Table 5 revealed 81.82% (9/11) and 91.91% (10/11) of standard treatments for prevalent diseases in the public and private sectors with the LP medicines was unaffordable respectively [[
Table 5 Affordability: cost required to cover full course standard treatment against the number of daily wages
Condition to be treated Drug name, strength, dosage form, dose, route of administration, frequency & treatment duration Treatment schedule The total amount of drug required to cover the complete treatment regimen* Unit Average drug Price per Unit (USD) Number of day's wage to pay for treatment Public facilities Private facilities Public facilities Private facilities Mild pneumonia Amoxicillin 125 mg/5 ml, OS, 30 mg/kg P.O. TID for 7 days 30 mg/kg × 14.5 kg × 3 × 7 days = 9135 mg = 365.4 mL mL 0.0082 0.0104 3.0 3.8 Severe pneumonia 1. if improves, switch to 'a' 2. if doesn't improve within 48 h, switch to 'b' Benzylpenicillin 1.2MIU, Injection, 50,000 units/kg, IM, every 6 h at least for 3 days 50,000 units/kg × 14.5 kg × 4 × 3 days = 8.7MIU ~ 9MIU = 8vial Vial 0.2620 0.4984 2.1 4.0 a. Amoxicillin125 mg/5 ml, OS, 30 mg/kg P.O. TID for 7 days 30 mg/kg × 14.5 kg × 3 × 7 days = 9135 mg = 365.4 mL mL 0.0082 0.0104 3.0 3.8 b. Ceftriaxone 1 g, Injection, 50 mg/kg/day, IV, for 5 days 50 mg/kg × 14.5 kg × 5 days = 3625 mg ~ 4 g = 4 vial Vial 0.6726 0.9114 2.7 3.7 Impetigo Cloxacillin 125 mg/5 ml, Syrup, 100 mg /kg/day P.O. for 7 days 100 mg/kg × 14.5 kg × 7 days = 10,105 mg = 101.5 mL mL 0.0101 0.0113 1.0 1.2 Diarrhea with some dehydration ORS to make 1 litter, 1sachet P.O. some dehydration 75 ml/kg × 14.5 = 1087.5 ml ~ 2sachet Sachet 0.0808 0.3137 0.2 0.6 Acute otitis media Amoxicillin 250 mg/ 5 ml, OS, 5 ml, P.O. TID for 10 days 3 × 5 ml × 10 days = 150 ml mL 0.0080 0.0107 1.2 1.6 Augmentin 156.25 mg/5 ml, OS, 5 ml, P.O. TID for 10 days 3 × 5 ml × 10 days = 150 ml mL 0.0223 0.0512 3.4 7.8 Asthma Salbutamol puff, 1-2puffs, 3–4 times a day 200doses of 1 inhaler Dose 0.0155 0.0177 3.1 3.6 Pain management Paracetamol suppository 125 mg, 15 mg/kg, QID for 1 day 15 mg/kg × 14.5 × 4 = 870 mg = 7supp ~ 10supp Supp 0.0521 0.4173 0.5 4.2 Pain management Ibuprofen 100 mg/5 ml, Syrup, 10 mg/kg, P.O. PRN 100 mg/5 ml of 100 mL mL 0.0120 0.0161 1.2 1.6
OS Oral Suspension, P.O Per oral, TID Three times a day, QID Four times a day, PRN When necessary, IM Intramuscular, IV Intravenous, Supp Suppository, USD United States of American Dollar *Average weight of 5 year age children in Ethiopia =14.5 kg
The availability and prices of LP EMs were demonstrated in Fig. 1 for public sectors. The percent availability for each EM was depicted on the x-axis and the MPR value on the y-axis. The Figure was divided into four quadrants, taking into account 80% availability and considering cut-off point MPR = 1.5. Quadrant IV contains EMs with low MPR and high availability. In this segment, only 4 EMs were found. In quadrant I, EMs with high MPR and low availability have been reported, suggesting that patients have trouble accessing and affording them. If there were no alternative medication for infectious diseases, the absence of chloramphenicol in in private sectors (Supplementary Fig. 1) and the high price and low availability shown in Fig. 1 would have made infection control potentially difficult.
Graph: Fig. 1 General analysis of medicine availability and retail price in the public sector. On the x-axis, the percent availability for each drug is depicted and on the y-axis, the MPR value is shown
The current study utilized Chahal, H.S. et al, work to present the cut-off for the EMs availability percent range. Accordingly, 6 and 12 EMs were highly available (> 80%) in the public and private sectors respectively [[
The average availability of LP medicines for children was fairly high in both sectors [[
PFSA, the country's largest source of medicine, is now turning its office work into the field [[
The average availability of medicines used to treat chronic conditions such as seizure disorders and asthma in children was low (≈42%) [[
Medicines offered free of charge from the public sectors like artesunate 60 mg and vitamin A were found below 50%. This is because malaria is a seasonal epidemic. Its drug stock usually varies. Only when the need arises, drugs such as artesunate and coartem are procured and refilled free of charge from the source (Regional Health Bureau). Otherwise, the inventory resides in the central store. Regarding vitamin A, the service is mainly provided by health posts and they were also not part of this research. Private sectors do not have much interest in stock because these drugs are dispensed free of charge and their demand is low. When they disregard isoniazid stocking, such lack of interest was assured. In addition, the prescriber's desire for other alternatives, the negative thinking relating to opioid abuse, and being categorized under the Narcotic and Psychotropic Substance (NPS), caused morphine not to be stocked.
Infectious diseases are known causes of childhood morbidity and mortality [[
Irrational antibiotic use, on the other hand, may decrease the availability of EMs during the study period in the study area. Since they are prescribed for diseases unconfirmed by laboratory diagnosis, such as for viral origin, or prescribed if not required, or the poor controlling system that could not give up obtaining them without a prescription for self-medication could affect the stock [[
The current study also showed that the overall retail prices of the LP medicines were higher than their IRPs. They were sold at 1.26 times their IRPs in the public sectors and 2.24 times their IRPs in the private sectors. Concerning substantially higher prices in private sectors compared to public sectors, this finding is similar to the studies done by Edao Sado and Alemu Sufa, and Sun X et al [[
Managing commonly prevalent conditions—acute and chronic— with standard treatment protocol using the LP medicines in the region was unaffordable (81.82% in public and 91.91% in private) as they cost a day's or above wage for the LPGW. This finding agrees with the findings of Edao Sado and Alemu Sufa, and Sun X et al [[
This study did not assess factors affecting or related to availability, price, and affordability.
The average availability of EMs for children in this work was fairly good. Public sectors have relatively higher availability than private sectors provided that government-subsidized, free of charge offered and public sectors only allowed to stock medicines were included in the study. However, the average LP MPR for public and private sectors being 1.57 and 2.54 times their IRPs compromises children's access to EMs respectively. Furthermore, being unaffordability of LP medicines for 81.82 and 90.91% of full-course standard treatments of prevalent conditions in the public and private sectors as they cost a day's or above wages for the LPGW respectively, lowering childhood morbidity and mortality questionable.
We thank the regional health bureau and research institute, zonal health departments, woreda health offices, public and private health facilities workers/owners, data collectors who directly or indirectly contributed to the study.
TT conceptualized, designed, and drafted the manuscript, performed the statistical analysis, and participated in the supervision; HA prepared the original draft, coordinated the study, and involved in the analysis of the data; GT participated in the designing and supervision of the study. All authors read and approved the final manuscript.
The author(s) received no financial support for the research and/or authorship of this article.
The datasets used and/or analyzed during the current study available from the first author on reasonable request (email: teffjan99@gmail.com).
Ethical clearance was obtained from Jimma University Institute of Health Sciences Ethical Review Board after the pharmacy department reviewed and approved the study protocol as it was complied with the Declaration of Helsinki. The board wrote a letter of support to the researchers to be presented to the SNNPR health bureau to obtain permission to conduct the research. Again the regional health bureau wrote a letter of support to the survey areas health departments to facilitate cooperation. Sectors provided informed verbal consent that was approved by the ethical review board of Jimma University to be interviewed. Confidentiality was ensured by assigning unique code for every outlet and site (Supplementary Annex I).
Not applicable.
The authors declare that they have no competing interests.
Graph: Additional file 1: Annex I. Information sheet and consent form. Annex II. Medicine price collection data form of public HF and private MOs. Annex III. Price in USD and IRP of children essential medicine in public and private sectors. Annex IV. Selected diseases from the top ten Prevalent childhood illness in the region to measure affordability for treatment. Supplementary Figure 1. General Analysis of Availability and Price for private sector. On the x-axis, the percent availability for each drug is depicted and on the y-axis, the MPR value is shown.
• CEMs
- Children essential medicines
• EMLc
- Essential medicine lists for children
• EMs
- Essential medicines
• ETB
- Ethiopian birr
• HAI
- Health action international
• HC
- Health center
• HFs
- Health facilities
• HP
- Highest-priced
• IRPs
- International reference prices
• LPGW
- Lowest-paid government unskilled worker
• LP
- Lowest-priced
• MPR
- Median price ratio
• MS
- Microsoft
• SNNP
- Southern nations nationalities and peoples
• WHO
- World health organization
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By Tefera Tadesse; Habtamu Abuye and Gizachew Tilahun
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