Survey of Medicine Prices, Availability, Affordability and Price Components in Mongolia

Publication date: 2004

SURVEY OF MEDICINE PRICES, AVAILABILITY, AFFORDABILITY AND PRICE COMPONENTS IN MONGOLIA Ms Ch. Munkhdelger, Head, Pharmaceutical and Health Devices Department, Ministry of Health, Mongolia November 2004 Survey funded: WHO/HAI Table of Contents Page ACKNOWLEDGEMENTS 3 ABBREVIATIONS 4 EXECUTIVE SUMMARY 5 Summary of Recommendations 5 1. INTRODUCTION AND BACKGROUND 5 Country information 5 The health situation 6 The pharmaceutical sector 7 2. METHODOLOGY 9 Which sectors were surveyed 9 Selecting geographic areas 9 Sampling facilities 10 List of medicines 10 3. DATA COLLECTION 12 4. RESULTS 12 Important notes 12 4.1 Public sector patient prices and availability 13 4.2 Private sector patient prices and availability 15 4.3 Community Revolving Drug Funds’ patient prices and availability 17 4.4 Public sector procurement 18 4.5. Inter-sector patient prices and availability comparisons 19 4.6 Affordability to patients 22 4.7 Price components and cumulative mark-ups 23 4.8 National prices in international perspective 25 5. DISCUSSION 25 6. CONCLUSIONS AND RECOMMENDATIONS 26 Annexes Annex 1: List of medicines surveyed (Product Table) 27 Annex 2: List of essential medicines 30 Annex 3: Timetable of survey 31 Annex 4: Analysis summary sheets 32 Annex 5: Medicines data collection form used in survey 39 Annex 6: National Pharmaceutical Sector Form, Mongolia 44 2 ACKNOWLEDGEMENTS This medicine price survey was conducted with financial and technical support of the WHO and Health Action International (Europe) Permission to undertake this survey was given by the Ministry of Health, Mongolia. Special gratitude is extended to Ms Margaret Ewen, Co-Director (Projects), Health Action International (Europe), Ms Kirsten Myhr, Head, RELIS Ost Drug Information Centre, Ulleval University Hospital for their invaluable guidance and involvement during the preparations, commissioning and completion of the survey. We wish to thank all the people who gave their precious time to provide data and area supervisors and data collectors. We also wish to express our thanks to the Advisory Group: Dr. Dungerdorj, the Main Specialist for Pharmaceuticals, MOH, D. Uranchimeg, Officer in charge for drug supply, Pharmacy Department, Directorate of Medical Services, O. Damba, the representative of Mongolian Pharmaceutical Association, D. Chuluuntsetseg, the Head of Department of Essential Medicine, “Mongol emimpex” concern. Ms Ch. Munkhdelger, Head, Pharmaceutical and Health Devices Department, Ministry of Health, Mongolia Government building, Olympic Str - 2, Ulaanbaatar - 210648 Mongolia e-mail: munkhdelger@moh.mn Tel: 976-11-261682 3 ABBREVIATIONS EML Essential Medicines List GDP Gross Domestic Product HAI Health Action International HIF Health insurance fund INN International non-proprietary name LPG Lowest Priced Generic Max Maximium Min Minimium MNT Mongolian Tugrug (currency) MOH Ministry of Health MPR Median Price Ratio MSG Most sold generic MSH Management Sciences for Health NA Not available NGO Non Government Organisation RDF Revolving Drug Funds UNICEF United Nations Children's Fund WHO World Health Organization US$ United States Dollar VAT Value Added Tax The terms "medicines" and "drugs" are used interchangeably in this report. EXECUTIVE SUMMARY The medicine price project has carried out a field study to measure the prices and availability of medicines in Mongolia using an international standardized methodology. 4 The results showed that in Mongolia, there is a limited market, particularly for innovator brand products, as well as poor affordability of medicines by customers. The innovator brand medicine, one key indicator of comparative medicine survey, was only found for one medicine. Among the 3 sectors, the most sold generic equivalent is more available in the private sector and lowest price generic equivalent is more available in the public sector. The prices obtained by public procurement are greater than the international standard. The prices charged for the most sold generic medicines in the private sector were almost two times the prices in the public sector, while the prices of the lowest price generic eqivalents were less than double the public sector patient price. Prices in the public sector and private sector are considerably higher if compared to international reference price. The prices of generic medicines also vary (one generic is different from another) and the cheapest product is not always the most sold in all sectors. For one month course of the lowest priced generic Ranitidine to treat peptic ulcer, a patient would need to pay the equivalent 1.8 days’ wages in public sector facilities and 3.1 days’ wages in private sector. Part of the problem is relatively high duties, tariffs and mark-ups. Summary of Recommendations 1. In all sectors medicine availability and the price regulation must be improved. 2. Appropriate regulations are needed to increase drug supply and lower the price. 3. Review and reduction of burden of duties, taxes and mark-ups on medicines is needed. 5 1. INTRODUCTION AND BACKGROUND The objectives of our study were: 1. To measure prices of selected medicines in different sectors, geographical areas, health facilities and pharmacies 2. To identify differences in the prices of innovator brand products and generic equivalents 3. To identify components of medicines prices 4. To assess affordability of the medicines Country information Mongolia is a large, landlocked and sparsely populated country in northern part of Central Asia, located between Russia on the north and China on the east, south and west. It’s total land area of 1,565,000 square kilometres contains only 2.4 million population (2000). More than 50% of the Mongolian population is urban and live In 22 cities, 20% of the population is nomadic. Urban growth levelled off in 1991 but rural growth continues to increase slowly. The climate of Mongolia is continental with four seasons and it endures long, severe winters, with average temperature as low as -32°C in January. Geography and climate thus combine to present significant difficulties for those who are tasked with planning and delivering health services. Mongolia has a parliamentary system of government. The country is divided into 21 aimags (provinces) which together with the autonomous capital region, form a second tier of government. The main pillar of the economy continues to be the agriculture sector, including livestock, which provided 20.7% of GDP in 2002. The other main sectors in 2002 were trade and services (27.6%), transport and communication (14.0%), manufacturing (9.5%) and mining (8.6%). Unemployment is 20%-30% of the workforce. Under-employment is a growing problem in both urban and rural settings. Poverty continues to be a profound problem for about one third of the population. 6 The Health situation Ensuring adequate health services throughout a sparsely populated (1.5 inhabitants per sq. km) terrain with extremes in climate is a challenging task in the health system. Until 1990, the Mongolian Health Care system was supported by the former Soviet Union. The system that was developed was effective in reducing the rapid spread and high burden of infectious diseases that was threatening to wipe out the Mongolian population. Mongolia is experiencing health problems associated with both third world and first world countries with constrained economic base. There are health problems related to high maternal and infant mortality, very high levels of sexually transmitted diseases and some communicable diseases. Many non-communicable diseases including cancer, cardiovascular diseases, and mental health issues are also common. The ability of the Government to provide social services and compensatory support is quite limited. Government spending on health has been about 4% of GDP and about 10% of the government budget in the most recent years. The Mongolian health care system consists of three levels. These are served by a variety of facilities. The relationship of the type of care and type of facilities and referral level are shown below: Table 1 Relationship of the Type of Care and Type of Facilities and Referral Level Level Type of care Type of facility UB City Rest of the country Referral level Primary General professional care FGP, Village hospital Bagh feldsher post, FGP, Soum / Intersoum hospital --- Secondary Specialized professional care Ambulatory and branches, District Hospital Inter-soum hospitals, Aimag ambulatory Aimag hospital, First referral level Tertiary Advanced specialized professional care Specialized hospitals, centres RDTC Second referral level Source: Minister’s order #A/361, 2000. The constitutional and health policies objectives are equitable access to health care for every citizen and the allocation of resources for health in relation to needs of the population in geographically different parts of the country. The pharmaceutical sector About 85% of medicines that Mongolia needs are imported. There is one state owned drug supplying company besides 50 privately owned small drug suppliers. The state drug wholesaler “Mongolemimpex” is a joint stock company with 51% of shares owned by state. With the advent of free market economy in the 1990s, Mongolia saw rapid growth in the private pharmaceutical sector. In 2004, there are 29 local manufacturers, 7 90 wholesalers and 807 pharmacies in the country (including pharmacy branches). Most pharmacies are private, except for state hospital pharmacies and soums1 pharmacies. Currently, 65% (221 soums) of all the soum pharmacies are supported by a Community and Health Project. The Community and Health Project was started in 1994 by the Ministry of Health in cooperation with UNICEF and supported by a grant from the Nippon Foundation. The project aimed to address the problem of the lack of essential drugs in rural areas by establishing Revolving Drug Funds (RDF) and to sustain primary health care services through the active participation of communities. This support has been the major international project in the pharmacy sector. The programme was quite successfully and will be established in the remaining soums in 2005. The MOH drug budget in 2004 was 78,631,231.9 MNT2 and it has been increasing substantially from previous years. (Exchange rate 1$=1207MNT) Table 2 Drug allocation in the health budget Year Drug budget (mln MNT) Total health expenditure (mln MNT) 1999 6,835.5 36,926.1 2000 7,960.4 46,860.6 2001 9,538.2 54,281.1 2002 9.379.7 57,662.2 2003 8,871.3 62,299.7 2004 10,362.3 78,631.2 Drugs for cancer, kidney dialysis, some psychiatric illnesses etc (total number of 55 medicines for 15 kinds of disease) are provided free of charge, through tertiary and secondary hospitals. There is also a reimbursement scheme for medicine costs. The items of reimbursable drugs as well as their prices were reviewed according to the existing list and prices. There are 127 medicines whose prices could be reimbursed by the health insurance fund based on prescriptions issued by family doctors (general practitioners). The pharmacist charges a designated percent of the retail cost at the pharmacy to the customer, and also applies for reimbursement of the retail cost of the medicines through the HIF. A new procedure to apply competitive bidding in procurement of medicines needed by state-run hospitals was introduced in 2002 to improve efficiency of the fund allocated for medicines. Key indicators to measure the availability and rational use of essential medicines, based on WHO indicators, are shown in Table 2. 1 A soum is a country’s administrative unit equivalent to district. 2 National currency 8 Table 3 The key indicators (2004) Indicators 2004 Availability of key medicines 77.9-96.0% Average number of medicines per patient 2.9 Average consultancy time on drug information 119 sec Percentage of medicines from the EML dispensed, out of total number of dispensed 59.4% Percentage of injections dispensed 12.1% Percentage of antibiotics dispensed 15.0% Percentage of vitamins dispensed 16.1% Percentage of generic medicines dispensed 50% Percentage of medicines adequately labelled 46% Most communities do not have enough money to buy necessary medicines, and low quality drugs are sold and irrational drug use is widespread. At the time of centralized economic practices in Mongolia, the Government used to fix the price for each of medicines and a single tariff was applied throughout the country. However, after the 1997 price liberalization, there was no more regulation from the Government and the price of medicines has gone up. 2. METHODOLOGY During the month of November 2004, a survey on measuring prices of medicines was undertaken. The survey was conducted as a cross-sectional survey based on a methodology developed by World Health Organization (WHO) and Health Action International (HAI), comparing the prices of medicines in different health sectors. Sectors surveyed The survey examined three sectors as follows: • Public sector • Private sector • Other sector (Drug Revolving Fund) We also looked at two prices in the public sector, i.e. procurement prices and prices charged to patients. The table below describes which sectors were surveyed and what was measured in each sector. 9 Table 4 Sectors which were surveyed Public sector Private sector DRF Price to the patient √ √ √ Procurement price √ Availability to patients √ √ √ Affordability by patients √ √ √ Selecting geographic areas The 4 geographic regions of Mongolia surveyed included the capital of the state, Ulaanbaatar, and 3 other aimags; Khovd (Atlai mountainous region), Umnugobi (Great Gobi region) and Dornod (Dornod Plain region). The regions were selected purposively considering transport and human capacity for undertaking survey. Tov Uvs Dornod Omnogovi Gobi-Altai Khovd Khentii Khovsgol Dornogobi Zavkhan Dundgobi Bayankhongor Sukhbaatar Bulgan Arkhangai Selenge Ovorkhangai Bayan-Olgii Gobisumber Ulaanbaatar 500 0 500 Miles N EW S Geographic regions surveyed Sampling facilities There are 4 state owned community pharmacies, 29 hospital pharmacies, 298 private pharmacies in Ulaanbaatar city. There is one state owned community pharmacy, a hospital pharmacy and 5-10 private pharmacies in each aimag center and a drug revolving fund in every soum. Clinical hospitals and professional centers regularly organize competitive bidding for procurement of medicines. Every aimag considers the medicine needs of all soums in the aimag, compiles these needs for the aimag and 10 organizes tenders. Clinical hospitals and the Health Department of aimags have their own tender committees. In view of the design of this study, the samples were selected according to the WHO/HAI manual in Ulaanbaatar city and aimag center. The public health facilities were selected, then the pharmacy that is closest to each facility was selected locally in the field by the supervisor. Public health facilities and RDF pharmacies were selected by the survey manager. A total of 52 pharmacies were surveyed: Ulaanbaatar: 1 State owned community pharmacy 5 hospital pharmacies (procurement prices only) 10 Private retail pharmacies Each aimag: 1 State owned community pharmacy 1 hospital pharmacies (procurement prices only) 5 Private retail pharmacies 5 Drug revolving fund pharmacies Treatment affordability was calculated for ten conditions using local price information and the daily wage rate of the lowest paid unskilled government worker. List of medicines The WHO/HAI methodology uses a selected number of medicines for which specific dosage forms and strengths are pre-determined; only prices and availability of these exact medicines, forms and strengths are collected. The selected medicines are made up of a core list of 30 medicines determined as part of the methodology for all countries and a supplementary list of up to 20 medicines which is determined by each individual country. A total of 33 medicines were included in the survey. Of these 18 medicines were core medicines and 15 were added by us as a supplementary list. Supplementary medicines were selected to reflect local disease patterns and important medicines for the country. The tables below lists the core medicines removed with the reason, and lists the supplementary medicines selected. A full list of all the medicines surveyed can be found in annex 2. Table 5 Core medicines removed Medicine Dosage form, strength Reason for removal 1 Artesunate 100 mg cap/tab Not marketed 2 Ceftriaxone injection 1 g/vial gram Different strength 3 Fluconazole 200 mg cap/tab Different strength 4 Fluoxetine 20 mg cap /tab Not marketed 5 Indinavir 400 mg cap/tab Not marketed 6 Losartan 50 mg cap/tab Not marketed 7 Lovastatin 20 mg cap/tab Not marketed 11 8 Nevirapine 200 mg cap/tab Not marketed 9 Phenytoin 100 mg cap/tab Not marketed 10 Zidovudine 100 mg cap/tab Not marketed 11 Nifedipine Retard 20mg tab Not marketed 12 Pyrimethamine+Sulfadoxine 25mg+500mg tab Not marketed Table 6 Supplementary medicines added Medicine Dosage form, strength Reason for addition 1 Ampicillin 500 mg tab Commonly used 2 Ceftriaxone injection 250 mg/vial Included core list with different strength 3 Chloramphenicol 500 mg cap/tab Commonly used 4 Clotrimazole 100 mg pessary Commonly used 5 Cephalexin 250 cap Commonly used 6 Fluconazole 150 mg cap/tab Included core list with different strength 7 Erythromycin 250 mg tab Commonly used 8 Furosemide 40 mg tab Commonly used 9 Gentamicin injection 40mg/ml Commonly used 10 Ibuprofen 400 mg tab Commonly used 11 Indomethacin 25 mg tab Commonly used 12 Mebendazole 100 mg tab Commonly used 13 Metronidazole 250 mg tab Commonly used 14 Propranolol 40 mg tab Commonly used 15 Reserpine 250 mcg tab Commonly used For each substance, the following three products were surveyed: • Innovator brand (identified centrally) • Most sold generic equivalent (identified centrally) We undertook an initial survey by telephone to identify the MSG product. • Lowest price generic equivalent (identified at the facility) Note: data on the MSG products of beclometasone inhaler and ceftriaxone injection was not included in the analysis as the products were incorrectly identified. Data was also not included for nifedipine retard 10mg tablets as there was no MSH price for this medicine. In all sectors we also measured the availability of the medicines at the time of data collection. All prices were converted to US dollars using the exchange rate on 5 November 2004, the first day of the survey. We also identified the components of medicine prices in order to better understand the different selling prices. 3. DATA COLLECTION All personnel involved in data collection and data entry were trained to ensure the reliable and accurate completion of the data collection forms and entry of the data. A pilot test was conducted during the training of data collectors. 12 Data were collected by asking the medicine price in pharmacies. Public procurement prices were collected from hospitals. Data on price components and their costs were collected centrally from wholelalers and pharmacies. Data entry and analysis took place at central level once each data collection form was reviewed for clarity and completeness. A computerized workbook developed by WHO/HAI, which is a special application of Microsoft Excel, was used to enter the data collected in the field, consolidate and summarize results. The data was double entered to ensure accuracy, and the automated autochecker was used to minimise any errors. Summary measures of the medicine prices found during the survey were expressed as ratios relative to a standard set of reference prices. The Management Sciences for Health prices (2003) were selected as the standard. The MSH reference prices are the medians of recent supplier procurement prices offered by not-for-profit (and sometimes for-profit) suppliers to developing countries for multi-source generically equivalent products. Where supplier prices were not available, agency prices were used as the reference. 4. RESULTS Our survey of 33 medicines in Mongolia revealed that the innovator brand medicine, one key indicator of comparative medicine surveys, was only found for one medicine (ceftriaxone in the private sector). This is related to Mongolia’s limited market and foreign trade scope as well as poor affordability of medicines by cus tomers. Important notes What is a median price ratio? (MPR) Results on medicine prices gathered by the WHO/HAI survey are usually expressed as “median price ratios” or MPRs. The MPR is a ratio of the local price divided by an international reference price (converted into the same currency). The reference price serves as an external standard for evaluating local prices. All studies are expected to use the same reference prices so that they will be comparable. The MPR results in this survey are based on reference prices taken from the 2003 Management Sciences for Health (MSH) International Drug Price Indicator Guide (http://erc.msh.org/). The MSH Guide pulls together information from recent price lists of large, non-profit generic medicine suppliers. These suppliers typically do not sell to individual private pharmacies. Rather, they sell in large quantities to governments and NGOs, and accordingly, prices in the MSH Guide tend to be low. But they offer a very useful standard against which locally available products can be compared in any country. Use of medians and averages As averages can be skewed by outlying values, median values are generally used (unless otherwise stated) throughout the presentation of results and discussion as a better representation of the midpoint value. 13 Reporting of quartiles/percentiles A quartile is a percentile rank that divides distribution into 4 equal parts. The range of values containing the central half of the observations: that is, the range between the 25th and 75th percentiles (the range including the values that are up to 25% higher or down to 25% lower than the median) is called the interquartile range. In this finding section, where medians and interquartile ranges are not presented in tables, the following format will be used to report the number of occurrences and the interquartile range. Affordability Affordability is the cost of treatment in relation to people’s income. In this survey, the daily wage of the lowest paid unskilled government worker is used for the comparison. Medicines which are unaffordable to this worker will be much less affordable for the significant proportion of the population that have an income less than this worker. Basket of medicines The basket of core and supplementary medicines should provide a reasonable representation of medicines in the country and price conditions on the market. Minimum data points for analysis Four data points for patient prices and one data point for procurement prices are the minimum number of data points that are necessary for the analysis to be performed by the workbook. If there are less data points are less than this, then no calculation of MPR is performed. Availability is however calculated for all medicines irrespective of the number of outlets stocking each medicine. 4.1 Public sector patient prices and availability (Annex 4B) Mongolia had a centralized medicine supply system and decentralization was started in mid -1990s. “Mongolemimpex” company was a monopoly state medicine wholesaler and distributor and it was privatized in 2003. Now the state drug wholesaler “Mongolemimpex” is a joint stock company with 51% of shares owned by the state. All public sector pharmacies belong to this company in Mongolia. The variation in results in the public sector was limited because the state company has a countrywide supply system and all public pharmacies are supplied with the same medicines. For instance, the nationally identified most sold generic products could rarely be found. No innovator brands were found. The lowest priced generic medicines were found to have a median MPR for the basket of 2.6 (n=19); however within the basket this varied from 0.79 for cephalexin to 55.06 for mebendazole. The most sold generic was rarely found in these pharmacies (median MPR was 2.31, n=2) The median availability of those medicines on the essential medicines list was found to be 72.7 %. The table below shows those medicines on the essential medicines list and their availability in the four state-owned community pharmacies. 14 Table 7 Availability of any generic in the public sector (n=4 facilities) Availability Medicine Not found Beclometasone inhaler, Co-trimoxazole suspension, Fluphenazine injection < 50% Ampicillin, Ibuprofen, Metformin 50-75% Chloramphenicol, Diazepam, Glibenclamide, Hydrochlorothiazide, Reserpine 75-100% Aciclovir, Amitriptyline, Amoxicillin, Atenolol, Captopril, Carbamazepine, Diclofenac, Erythromycin, Furosemide,Gentamicin injection, Indomethacin, Mebendazole, Metronidazole, Omeprazole, Propranolol, Ranitidine, Salbutamol inhaler 4.2 Private sector patient prices and availability (Annex 4c) The median availability of medicines in private sector was quite good, 42% for most sold generic medicines and 80% for any generic eqivalent. The reason for the low availability of most sold generics is that the urban and rural areas have different supply sources in Mongolia. Some companies supply only in the big cities and some wholesalers distribute to rural areas. Therefore national identification of “most sold” generic product was extremely difficult. For the patient this is not a problem as long as there is at least one generic available. Some individual medicines had low availability in the private sector, namely, ceftriaxone, cephalexin, co-trimoxazole susp, diazepam, fluconazole, and metformin. We found only one item of innovator brand within all sectors during the survey. This was ceftriaxone injection and it was priced at 6.4 times the international reference price. For generically equivalent products, the difference in price between the most sold and the lowest price was not so large. The median of the median price ratios of the lowest price generic products was 4.17 times the international reference price. However within the basket this varied from 0.75 for reserpine and 120.13 for fluconazole. Table 8 lists median price ratios for individual generic medicines found to be greater than the median MPR for all the medicines surveyed in the private sector Table 8 Lowest priced generic medicines whose MPR is greater than the median MPR Medicine Strength MPR 1 Amitriptyline 25 mg 7.63 15 2 Atenolol 50 mg 7.57 3 Ceftriaxone injection 250 mg/vial 5.27 4 Ciprofloxacin 500 mg 6.51 5 Clotrimazole 100 mg 4.17 6 Co-trimoxazole suspension 8+40 mg/ml 8.63 7 Diazepam 5 mg 11.84 8 Diclofenac 25 mg 11.78 9 Fluconazole 150 mg 120.13 10 Glibenclamide 50 mg 7.58 11 Hydrochlorothiazide 25 mg 30.77 12 Ibuprofen 400 mg 7.80 13 Indomethacin 25 mg 4.76 14 Mebendazole 100 mg 26.94 15 Metronidazole 250 mg 6.72 16 Propranolol 40 mg 6.50 Figure 1 Variability of lowest priced generic medicines in the private sector – showing ratios for 25th percentile, 75th percentile and median (diamond shape) 0 5 10 15 20 25 30 35 Am itri pty lin e Ate no lol Cip rof lox ac in Co -tri mo xa zo le su sp Dia ze pa m Dic lof en ac Ge nta mi cin in j Hy dro ch lor oth iaz ide Me be nd az ole Pr op ran olo l Ra nit idi ne Pr ic e R at io 's - 25 th & 7 5t h pe rc en til e an d m ed ia n As this graph shows, the interquartile ranges (i.e. 50% of the prices collected for that medicine) showed little variability for many lowest priced generics (except cotrimoxazole susp, diclofenac, hydrochlorothiazide and mebendazole) The following lowest priced generic medicines had very little price variation across the pharmacies sampled: amoxicillin, ampicillin, chloramphenicol, erythromycin, omeprazole, reserpine and salbutamol inhaler. For amoxicillin and chloramphenicol there were no difference between MPR for the most sold and lowest price generic equivalent product and 50% of the pharmacies had 16 the same price. One explanation for the same price for different products is that these two products are produced by local manufacturers and supply is stable. Figure 2 Median price ratios, private sector 17 0 20 40 60 80 100 120 140 Aciclovir Amitriptyline Amoxicillin Ampicillin Atenolol Captopril Carbamazepine Ceftriaxone injection Chloramphenicol Ciprofloxacin Clotrimazole Co-trimoxazole suspension Diazepam Diclofenac Erythromycin Fluconazole Furosemide Gentamicin Glibenclamide Hydrochlorothiazide Ibuprofen Indomethacin Mebendazole Metformin Metronidazole Omeprazole Propranolol Ranitidine Reserpine Salbutamol inhaler Median price ratio Low est price generic Most sold generic Innovator brand The range between the Min and Max MPR for most sold and lowest price generic equivalent products are identical and very large 0.75 - 120.13. It means that a product could be cheaper than the international reference price (reserpine tabs), but could also be as high as 120 times that price (fluconazole 150mg tabs). The reasons for the high prices for some drugs (mebendazole, hydrochlorothiazide and fluconazole) are because they are supplied by only one distributer and the generics are branded. 18 4.3 Community Revolving Drug Funds’ patient prices and availability (Annex4) Revolving Drug Funds were created with assistance from UNICEF and functions in about 70% of soums and will be established in remaining soums in 2005. The properties of the RDFs are owned by the community and the fund is used for supplying medicines for the local area. The median availability of MSG is not very high but was 73% for LPG in the soums. The range between 25th and 75th percentiles and between the Minimium and Maximium shows wide variation in availability in soum RDF. No innovator brand was found in the outlets. The median of the median price ratios of the most sold generic equivalents was 4 times the international reference price, with half of medicines being sold in the range of 2.0 to 7.3. The median of the median price ratios of the lowest price generic equivalents was 4 times the reference price, with 50% of the medicines in the range of 2.2 to 7.1. 4.4 Public sector procurement (Annex 4a) A new procedure to apply competitive bidding in procurement of drugs needed by state-run hospitals was introduced in 2002 to improve efficiency of the fund allocated for medicines. Clinical hospitals and professional centers regularly organize themselves for competitive bidding for procurement of medicines. Each aimag considers medicine needs of all soums of the aimag, compiles a list for aimag needs and organizes a tender. Clinical hospitals and Health Department of aimags have their own tender committees. We collected 8 medicine orders to study procurement price data. There was no innovator brand in the orders. The Mongolian procurement price is not close to international standard, with typical ratios between 2.2 and 2.4. These prices obtained are quite high by international standards. The difference in price between the most sold and the cheapest was small. The median of the median price ratios of the lowest price generic equivalents was 2.3 times the international reference price. It shows that the fluctation of price is high and stabilization of the medicine market is very low. Figure 3 Median price ratios for procurement prices (lowest priced generic) 19 0 5 10 15 20 25 30 35 40 45 Aciclovir Amitriptyline Amoxicillin Ampicillin Atenolol Captopril Carbamazepine Ceftriaxone injection Chloramphenicol Ciprofloxacin Clotrimazole Diazepam Diclofenac Erythromycin Furosemide Gentamicin Glibenclamide Hydrochlorothiazide Ibuprofen Indomethacin Mebendazole Metformin Metronidazole Omeprazole Propranolol Ranitidine Reserpine Salbutamol inhaler M ed ic in es Median price ratio 4.5 Inter-sector patient prices and availability comparisons (Annex 4e) The survey shows that procurement prices in the public sector were lower than the patient prices in all four sectors studied. Figure 4 Inter sector patient prices 20 2.39 2.52.31 2.6 6.4 4.12 4.173.99 3.99 0 1 2 3 4 5 6 7 Innovator Brand (One item) Most sold generic equivalent Lowest price generic equivalent Products M ed ia n M P R Procurement (n=8 orders) Public (n=4 outlets) Private (n=25 outlets) RDF (n=15 outlets) Sectors Our survey of prices of brand and generic medicines in Mongolian public, private and DRF sectors shows very low availability of innovator brand medicines. This is, however, not a problem if generics, which are normally cheaper, are available. Most public and private outlets and hospitals have only one or two products for each medicine. Therefore, the MPRs for most sold and lowest price generic equivalents are almost the same in the various sectors.  Public sector patient prices for lowest priced generics were on average 36 % more than the public sector procurement prices (n=18 medicines)  Private sector patient prices for lowest priced generics were 33 % more than the public sector patient prices (n= 18 medicines)  DRF sector patient prices for lowest priced generics were 33 % more than the public sector patient prices (n= 18 medicines)  DRF sector prices were the same as private sector prices (n= 25 medicines) The following medicines are much more expensive in the private sector than public sector except for mebendazole. Table 9 Comparison of median price ratios for the lowest priced generics in the public and private sectors Medicine Public sector MPR Private sector MPR Ratio private to public Dfference private to public Amitriptyline 5.52 7.63 1.38 38.2% Atenolol 3.93 7.57 1.92 92.6% Carbamazepine 1.92 3.33 1.73 73.4% Mebendazole 55.06 26.94 0.49 -51% Propranolol 4.47 6.5 1.45 45% Ranitidine 2.31 3.99 1.72 72.7% 21 Some medicines have high retail prices in the public sector when compared to their procurement price. Table 10 Comparison of median price ratios for the lowest priced generic - procurement price and public sector patient price Public Procurement price (MPR) Public Sector patient price (MPR) Ratio public sector patient price to procurement price Difference public sector patient price to procurement price Captopril 1.58 2.89 1.82 82.9% Clotrimazole 2.5 3.82 1.52 52.8% Diclofenac 8.93 10.56 1.18 18.2% Furosemide 1.73 2.07 1.19 19.6% Indomethacin 3.33 4.98 1.49 49.5% Mebendazole 40.41 55.06 1.36 36.2% Metrionidazole 3.69 5.93 1.60 60.7% Propranolol 3.57 4.47 1.25 25.2% Some medicines are almost the same price in the private sector as the public sector – amoxicillin, captopril, clotrimizole, erythromycin, furosemide, indomethacin, salbutamol inhaler and omeprazole Figure 5 Cross sector medicine availability by product type includes both core and supplementary Medicines (n=33 on list) 25 44 26.7 100 80 73.3 0 20 40 60 80 100 120 Public (n=4 outlets) Private (n=25 outlets) RDF (n=15 outlets) M ed ia n % a va ila bi lit y Most sold generic equivalent Lowest price generic equivalent Our survey of prices of innovator brand and generic medicines in Mongolian public, private and other sectors shows very low availability of innovator brand medicines. Among the 3 sectors, the most sold generic equivalent (MSG) is more available in the private sector and lowest price generic equivalent (LPG) is more available in the public sector. The reason for higher MSG availability in private sector, is that for this survey, 22 the product was identified in this sector. Normally, the public sector carries a different range of products as they are purchased by tender and these have been entered as LPGs in the study. Regional variations of prices and availability Table 11 Comparison of medicine availability in each region Regions Private sector RDF sector Khangai, Khentii mountainous 80 % NA Dornod Plain 100 % 60 % Great Gobi 60 % 80 % Atlai mountainous 80 % 60 % Figure 6 Comparison of Median Price Ratios 4 different geographic areas 2.84 2.62 2.54 3.03 4.29 4.17 4.08 3.53.45 4.21 4.08 0 0.5 1 1 .5 2 2.5 3 3.5 4 4.5 5 Khangai, Khentii mountainous Dornod Plain Great Gobi Atlai mountainous Regions M ed ia n M P R Procurement Private RDF Figure 6 shows MPRs in 4 different geographic areas surveyed in Mongolia, for three sectors. The comparisons suggest that MPRs were very similar over the 4 geographic areas except Altai mountains region. The median MPR of medicine in altai Mountains region is relatively low. The median MPR of medicines for RDF of Khangai khentii mountain region is lower than other regions. 4.6 Affordability to patients Affordability is the cost of treatment in relation to people’s income. In this survey, the daily wage of the lowest paid unskilled government worker is used for the comparison. The monthly salary of this worker is 49500 tugrug i.e 2292.9 tugrug per day (1$=1207 MNT). Figure 7 Comparison of affordability of treatment of some conditions if the cheapest generic is purchased in each of the 3 sectors 23 0 0.5 1 1 .5 2 2.5 3 3.5 D ep re ssion (Am itrip ty line) H ype rte ns io n (A teno lo l) A rth ritis (D ic lo fe na c) Pep tic u lce r (R an itid in e) N u m b er o f d ay s' w ag es Pub lic P riva te RDF Table 12 Cost of treatment for pneumonia and hypertension Treatment Type Public sector Private pharmacies Median price Days’ wages Median price Days’ wages Pneumonia: Amoxicillin 250 mg x 3 for 7 days Innovator brand NA NA NA NA Most sold generic equivalent NA NA 1260 0.5 Lowest price generic equivalent 1134 0.5 1260 0.5 Peptic ulcer: Ranitidine 150 mg x 2 for 30 days Innovator brand NA NA NA NA Most sold generic equivalent NA NA 7350 3.2 Lowest price generic equivalent 4170 1.8 7200 3.1 Table 12 illustrates the affordability in the public and the private sectors for one acute and one chronic condition. The 7 days’ treatment course with amoxicillin for pneumonia requires the equivalent of 0.5 days’ wages to be treated by lowest price generic equivalent in public sector health facilities. It is same in private sector, requiring 0.5 days’ wages. For a one month course of most sold generic ranitidine to treat peptic ulcer, a patient would need to pay the equivalent of 3.2 days’ wages, in the private sector. Buying the lowest price generic equivalent is slightly cheaper with 1.8 days’ wages in public sector facilities and 3.1 days’ wages in private pharmacies 24 Table 13 The effect of choice of therapeutic group to treat the same diagnosis Condition Choice of medicine Number of days’ wages Ratio of cost in comparison with the most affordable Hypertension Atenolol 1.1 1:1 Hydrochlorothiazide 1.7 1:1.5 Captopril 2.4 2.1 Diabetes Metformin 1.0 1:1 Glibenclamide 1.0 1:1 4.7 Price components and cumulative mark-ups (Annex 7) Table 14 Price components and cumulative mark-ups Component Imported product private sector Locally produced generic equivalent, public sector tender % Value % Value Import price 100.0 100 Customs duty 5% 105.0 Stamp duty 1% 106.05 Whole sale mark -up 25% 132.56 15% 115.00 Retail mark-up 30% 172.33 Value Added Tax (VAT) 15% 198.41 15% 132.25 Sales price 198.41 132.25 Total add-ons (cumulative mark-up) 98.41% 32.25% Table 14 shows the price components of an imported product in the private sector and a locally produced generic equivalent purchased on the public sector. The results are given both as percentage add-on and cumulatively. It shows how a base price including ex-factory cost, insurance, and freight rises incrementally as it makes its way through the standard distribution channels. Annex 7 shows the price components of three medicines. The price components on all imported medicines are the same. First two charges (customs duty 5% and stamp duty 1%) would not be included in the locally produced generic medicines. The mark-ups are lower in the public sector but add-ons constitute 32% of the final price. If customs, stamps, duty and VAT were removed the additional cost would be reduced from 98.4% to 62.5%. Table 15 Cumulative mark-up – local manufactured product, private sector Type of charge Charge Basis Amount of Charge Price of Dispensed Quantity Cumulative % Mark-Up Difference in cumulative mark-up Amount in currency % of final price Manufactured selling price NA NA 80 0.00% 80.00 53.5% Wholesaler mark-up percent 25.00% 100 25.00% 25.00 20.00 13.4% Retail mark-up percent 30.00% 130 62.50% 37.50 30.00 20.1% 25 VAT percent 15.00% 149.5 86.90% 24.40 19.50 13.0% 86.90 149.50 100.0% Figure 8 Component costs for imported products in the private sector as a percentage of the CIF price 26,51% 39,77% 25,85% 5,00% 1,05% 0% 20% 40% 60% 80% 100% 1 Customs tax Stamp duty Wholesaler mark-up Retailer mark-up Value Added Tax Figure 9 Difference in cumulative mark-up 25.00 37.50 24.40 0 20 40 60 80 100 1 wholesale margin retail margin VAT Figure 10 Percentage of final price 26 Cost insurance freight (CIF) price, 53.5%wholesale margin, 13.4% retail margin, 20.1% VAT, 13.0% 4.8 National prices in international perspective Table 16 Price ratio for ranitidine in private sector in Mongolia compared to comparable developing countries Ranitidine Median price ratio India Ghana Armenia Peru Mongolia Innovator brand 0.2 44.2 19.62 12.14 Most sold generic equivalent 0.2 16.35 1.99 4.08 Note: the above data was taken from HAI’s web site. The surveys were undertaken in different years (2001-2003) and the MSH price for ranitidine varied across these years. Only the most sold generic equivalent is on the market in Mongolia. Relatively competitive prices were found for India. The price of ranitidine is generally high. There is a notably sharp brand premium in Peru. Mongolia’s price for the generic is relatively high compared to Peru and India. 5. DISCUSSION Our survey of prices of brand and generic medicines in Mongolian public, private and drug revolving fund sectors shows very low availability of innovator brand medicines. Mainly generic medicines of various manufacturers from developed countries are being imported, so most of the data collected is for these medicines. The innovator brand medicine could not be found in pharmacies that were sampled in our survey and therefore, we had to compare the prices of the most sold and the lowest price generic equivalents in the different sectors. It was quite common to have the same price for the two since most of the pharmacies sold one item of a medicine from one manufacturer only so the most sold generic may also be the lowest priced. We also noticed that in each geographical region, mostly products of a single manufacturer were found. For example: products of a particular manufacturer that were available in pharmacies in Ulaanbaatar were not available in aimags This is related to the fact that there is no nationwide drug supplier except for the State Drug Supplying Company, Mongolemimpex. 27 The comparative study of the national and international reference price and the availability shows that the types of locally produced products have relatively stable prices in the market. There was little price difference between the drugs sold in public sector, private sector and drug revolving fund’s pharmacies. The procurement prices in the public sector was much lower than the patient prices in all three sectors studied. There was wide variation (26.1%) between public sector procurement and patient prices. However, the public sector procurement is not always efficient, as shown by the fairly high MPRs compared to the international reference prices for some items. If we look at the prices and availability of medicines in public sector, private sector and drug revolving fund pharmacies, it is easy to understand the need for some kind of price regulation and policy coordination. We have noticed that this need has direct impact on the outcomes of hospital treatments and on both the in-patient and out- patient services. A worker pay 0.5 days’ wages to treat an infection using amoxicillin but would pay 24.4 days’ wages using ceftriaxone injection (48.8 times –or an extra 24 days work). During the survey, it was difficult to find some of the indicators, which were supposed to constitute the basis for price comparisons. For example: manufacturer price of the imported medicines, the wholesale price and any extras added by the pharmacies varied greatly and made calculations difficult. The comparisons made include all the duties, including the VAT, customs duty, and transportation cost and registration fee, imposed by Mongolia’s currently effective legal acts. For imported generic medicines, the add-ons to the import price almost double the price. Many other countries do not charge taxes or duties on medicines and if the government of Mongolia chose to exempt medicines from taxes and duties this would reduce prices in the private sector by about 30%. 6. CONCLUSIONS AND RECOMMENDATIONS The principal conclusions of the study are as follows: • The almost non-existence of innovative brand medicines in the market is related to the import scope and the national purchasing power. • The prices of generic medicines vary and the cheapest generic equivalent is not always the most sold. • Public sector is not very efficient in procurement and charges reasonably high prices to patients compared to international prices. • The availability of medicines in all sectors is relatively low. • Prices show that medicines are relatively expensive compared to other countries prices. • The government policy and intervention is absolutely essential for the price of medicines, their mark-ups, VAT and the number of pharmacies. • Appropriate regulations are needed to increase drug supply and control prices. 28 On the basis of the findings of the study, the following recommendations are made to the policy makers. 1. Activities should be undertaken for proper enforcement of the State Drug Policy provisions on price and supply of medicines. 2. The public sector’s drug availability and the price regulation must be improved. 3. An in-depth study should be initiated to investigate the private sector that is booming at random under market conditions. • Increased number of private pharmacies in rural areas. • Study and conclusion on greater differences of prices on generic medicines in the private sector procured from varying manufacturers. • Consolidated receipt of statistical data from the private sector and establishment of standards for pharmacies 4. Steps should be taken to stabilize the price following the price reduction of medicines and promote the foreign trade. Policy options include: • Review and reduce or eliminate the burden of duties and taxes • Reduce mark-ups on medicines • Promotion of the medicines import with tax concessions and improved, budget efficiency • Break into two exempt taxes and duties reduce markups. 5. Increased supply and affordability of National essential drugs must become the main policy. • Reduction of price variations through the price policy on insurance and free medicines as well as prescribed medicines 29 Annex 1: List of medicines surveyed (Product Table) No. Medicine Name Medicine Strength Dosage Form Target Pack Size Core List "Innovator" Product Most Sold Generic Version (Nat'l) Cou ntry Name Manufacturer Co unt ry Name Manufacturer 1 Aciclovir 200 mg cap/tab 25 yes Zovirax GSK Acilovira Ferein 2 Amitriptyline 25 mg cap/tab 100 yes Tryptizol MSD Amittriptylino 25 Enddokrinini ai 3 Amoxicillin 250 mg cap/tab 21 yes Amoxil GSK Philco amoxy Philco Pharma 4 Ampicillin 500 mg tab 10 no Pentrexyl BMS Piloco ampi Philco Pharma 5 Atenolol 50 mg cap/tab 60 yes Tenormin Astra Zeneca Atenolol Akri Akrikhin 6 Beclometasone inhaler 0.05 mg/dose dose 200 yes Becotide GSK 7 Captopril 25 mg cap/tab 60 yes Capoten BMS Lemcapril 25 Hans E Lembcke 8 Carbamazepine 200 mg cap/tab 100 yes Tegretol Novartis Convulem-200 Hans E Lembcke 9 Ceftriaxone injection 250 mg/vial vial 1 no Rocephin Roche 10 Cephalexin 250 mg cap 10 no Keflex Eli Lilly Ospexin Biochemie 11 Chloramphenicol 500 mg cap/tab 10 no Chloromycetin PD/Pfizer Chloramphenic ol Monos Pharm 12 Ciprofloxacin 500 mg cap/tab 1 yes Ciproxin Bayer Philco cipro Philco Pharma 13 Clotrimazole 100 mg pessary 21 no Canestan Bayer Lemnesten 100 Hans E Lembcke 14 Co-trimoxazole suspension 8+40 mg/ml millilitre 70 yes Bactrim Roche Letrim-2880 Hans E Lembcke 15 Diazepam 5 mg cap/tab 100 yes Valium Roche Diazepam Laboratorio Farmacologic o Milanes25 16 Diclofenac 25 mg cap/tab 28 yes Voltaren Novartis Diclodenk Denkpharm 17 Erythromycin 250 mg tab 10 no Erythrocin Abbott Erythromycin Syntex 18 Fluconazole 150 mg cap/tab 30 no Diflucan Pfizer Diflazon KRKA 19 Fluphenazine injection 25 mg/ml millilitre 1 yes Modecate Sanofi- With/BMS Fluphenazine dec. Rotex Medica 20 Furosemide 40 mg tab 10 no Lasix Hoechst Furosemide Monos Pharm 21 Gentamicin injection 40mg/ml millilitre 1 no Garamycin Schering Philco genta80 Philco Pharma 22 Glibenclamide 5 mg cap/tab 60 yes Daonil HMR Mannil-5 Berlinkhemie 23 Hydrochloro thiazide 25 mg cap/tab 30 yes Dichlotride MSD Hypothiazide Sanofi- Synthelab 24 Ibuprofen 400 mg tab 20 no Brufen Knoll Lemprofen 400 Hans E Lembcke 25 Indomethacin 25 mg tab 10 no Indocid MSD Indomon Monos Pharm 26 Mebendazole 100 mg tab 6 no Vermox Janssen Mebendazole Hans E Lembcke 27 Metformin 500 mg cap/tab 100 yes Glucophage Merck Metformin Denk500 Denk Pharma 28 Metronidazole 250 mg tab 20 no Flagyl Rhone Poulenc Philco metro250 Philco Pharma 29 Omeprazole 20 mg cap/tab 30 yes Losec Astra Zeneca Lemloc-20 Hans E Lembcke 30 Propranolol 40 mg tab 20 no Inderal Astra Zeneca Propranolol Balkan pharma 31 Ranitidine 150 mg cap/tab 60 yes Zantac GSK Kalamtac Hans E Lembcke 32 Reserpine 250 mcg tab 100 no Serpasil Biochemie/ Ciba Reserpine Oterop 33 Salbutamol inhaler 0.1 mg/dose dose 200 yes Ventoline GSK Salbutamol Moskhimphar m repatai 31 Annex 2: List of essential medicines Note: 29 of the 33 core and supplementary medicines surveyed are currently on the essential medicines list (2001 edition) Medicine name Health care level Primary Secondary Tertiary 1 Aciclovir Yes Yes Yes 2 Amitriptyline Yes Yes Yes 3 Amoxicillin Yes Yes Yes 4 Ampicillin Yes Yes Yes 5 Atenolol Yes Yes Yes 6 Beclometasone Yes Yes Yes 7 Captopril Yes Yes Yes 8 Carbamazepine No Yes Yes 9 Ceftriaxone No No No 10 Cephalexin No No No 11 Chloramphenicol Yes Yes Yes 12 Ciprofloxacin No No No 13 Clotrimazole No No No 14 Co-trimoxazole Yes Yes Yes 15 Diazepam Yes Yes Yes 16 Diclofenac No Yes Yes 17 Erythromycin Yes Yes Yes 18 Fluconazole No No No 19 Fluphenazine decanoate No Yes Yes 20 Furosemide Yes Yes Yes 21 Gentamycin No Yes Yes 22 Glibenclamide Yes Yes Yes 23 Hydrochlorothiazide Yes Yes Yes 24 Ibuprofen Yes Yes Yes 25 Indomethacin Yes Yes Yes 26 Mebendazole Yes Yes Yes 27 Metformin Yes Yes Yes 28 Metronidazole Yes Yes Yes 29 Omeprazole Yes Yes Yes 30 Propranolol Yes Yes Yes 31 Ranitidine No Yes Yes 32 Reserpine Yes Yes Yes 33 Salbutamol Yes Yes Yes 32 Annex 3: Timetable of survey Date Appoint advisory group and survey planning and preparations from 5 July 2004 to 10 August, 2004 Training of data collectors 30 October, 2004 Data collection period from 05 Nov, 2004 to 12 Nov, 2004 Data analysis from 1 Dec. 2004 to 31 Dec, 2004 Preparation of draft reports from 31 Dec 2004 to 15 Jan, 2005 Stakeholder meeting from 1 February 2005 to 15 March, 2004 Final report published Implementation of advocacy and dissemination plan 33 Annex 4: Analysis summary sheets 4. a. Public sector - procurement prices Analysis Includes All Meds. With 1+ Procurement Prices Brand Most Sold Lowest Price Brand Most Sold Brand Lowest Price Most Sold Lowest Price No. of meds. included 0 24 28 0 0 0 0 24 24 Median MPR 2.39 2.50 2.39 2.29 25 %ile MPR 1.44 1.54 1.44 1.54 75 %ile MPR 4.02 4.69 4.02 4.35 Minimum MPR 0.59 0.59 0.59 0.59 Maximum MPR 24.14 40.41 24.14 24.14 Procurement Prices for Both Types in Pair Number of Medicines For Which 1+ Procurement Prices Were Found Summary of Medicine-specific Median Price Ratios (MPRs) For Meds. With 1+ Procurement Prices Analysis Includes Only Meds. With 1+ Reference Price Data Used = MSH 2003 Medicines Procurements (n= 8 in survey) Includes Both Core and Non-Core Medicines (n=33 on list) 4.b. Public sector - patient prices Analysis Includes All Meds. Brand Most Sold Lowest Price Brand Most Sold Brand Lowest Price Most Sold Lowest Price Median availability 0.0% 25.0% 100.0% 25 %ile availability 0.0% 0.0% 75.0% 75 %ile availability 0.0% 50.0% 100.0% No. of meds. included 0 2 19 0 0 0 0 2 2 Median MPR 2.31 2.60 2.31 2.31 25 %ile MPR 1.55 1.94 1.55 1.55 75 %ile MPR 3.06 4.72 3.06 3.06 Minimum MPR 0.79 0.79 0.79 0.79 Maximum MPR 3.82 55.06 3.82 3.82 Overall Percent Availability of Medicines on List in Outlets Included in Analysis Analysis Includes Only Medicines With Prices Found for Both Types in Pair Number of Listed Medicines For Which Prices Were Found in 4+ Outlets Summary of Medicine-specific Median Price Ratios (MPRs) For Meds. Found in 4+ Outlets Reference Price Data Used = MSH 2003 Includes Both Core and Non-Core Medicines (n=33 on list) Public sector Medicines Outlets (n=4 in survey) 34 4.c. Private sector pharmacies – patient prices Analysis Includes All Meds. Brand Most Sold Lowest Price Brand Most Sold Brand Lowest Price Most Sold Lowest Price Median availability 0.0% 44.0% 80.0% 25 %ile availability 0.0% 24.0% 32.0% 75 %ile availability 0.0% 68.0% 96.0% No. of meds. included 1 28 29 0 0 0 0 28 28 Median MPR 6.40 4.12 4.17 4.12 4.08 25 %ile MPR 6.40 2.52 2.54 2.52 2.53 75 %ile MPR 6.40 7.89 7.63 7.89 7.59 Minimum MPR 6.40 0.75 0.75 0.75 0.75 Maximum MPR 6.40 120.13 120.13 120.13 120.13 Analysis Includes Only Medicines With Prices Found for Both Types in Pair Overall Percent Availability of Medicines on List in Outlets Included in Analysis Private sector Medicines Outlets (n=25 in survey) Number of Listed Medicines For Which Prices Were Found in 4+ Outlets Summary of Medicine-specific Median Price Ratios (MPRs) For Meds. Found in 4+ Outlets Reference Price Data Used = MSH 2003 Includes Both Core and Non-Core Medicines (n=33 on list) 4.d. RDF pharmacies (‘Other’ sector) – patient prices Analysis Includes All Meds. Brand Most Sold Lowest Price Brand Most Sold Brand Lowest Price Most Sold Lowest Price Median availability 0.0% 26.7% 73.3% 25 %ile availability 0.0% 6.7% 40.0% 75 %ile availability 0.0% 40.0% 93.3% No. of meds. included 0 19 25 0 0 0 0 19 19 Median MPR 3.99 3.99 3.99 3.99 25 %ile MPR 1.99 2.24 1.99 2.30 75 %ile MPR 7.26 7.13 7.26 7.11 Minimum MPR 0.79 0.75 0.79 0.75 Maximum MPR 23.67 40.41 23.67 18.94 Analysis Includes Only Medicines With Prices Found for Both Types in Pair Overall Percent Availability of Medicines on List in Outlets Included in Analysis Other sector Medicines Outlets (n=15 in survey) Number of Listed Medicines For Which Prices Were Found in 4+ Outlets Summary of Medicine-specific Median Price Ratios (MPRs) For Meds. Found in 4+ Outlets Reference Price Data Used = MSH 2003 Includes Both Core and Non-Core Medicines (n=33 on list) 35 4.e. Sector availability and price summary – core medicines Procure- ment (n=8 orders Public Sector (n=4 outlets) Private Sector (n=25 outlets) Other Sector (n=15 outlets) Brand NA 0.0% 0.0% 0.0% Most Sold NA 0.0% 40.0% 20.0% Lowest Price NA 100.0% 64.0% 56.7% # Prices Required 1 4 4 4 Brand 0 0 0 0 Most Sold 14 0 15 8 Lowest Price 15 10 16 13 Brand Most Sold 2.71 4.08 5.12 Lowest Price 2.50 2.46 5.25 3.99 Procure- ment (n=8 orders Public Sector (n=4 outlets) # of Meds. in Both Sectors Ratio Public to Procure- ment Procure- ment (n=8 orders Private Sector (n=25 outlets) # of Meds. in Both Sectors Ratio Private to Procure- ment Brand 0 Brand 0 Most Sold 0 Most Sold 2.50 4.08 13 163.2% Lowest Price 1.95 2.46 10 126.1% Lowest Price 2.50 3.99 15 159.9% Procure- ment (n=8 orders Other Sector (n=15 outlets) # of Meds. in Both Sectors Ratio Other to Procure- ment Public Sector (n=4 outlets) Private Sector (n=25 outlets) # of Meds. in Both Sectors Ratio Private to Public Brand 0 Brand 0 Most Sold 2.34 5.12 8 219.1% Most Sold 0 Lowest Price 2.08 3.99 13 192.0% Lowest Price 2.46 3.11 10 126.6% Public Sector (n=4 outlets) Other Sector (n=15 outlets) # of Meds. in Both Sectors Ratio Other to Public Private Sector (n=25 outlets) Other Sector (n=15 outlets) # of Meds. in Both Sectors Ratio Other to Private Brand 0 Brand 0 Most Sold 0 Most Sold 4.08 3.99 7 98.0% Lowest Price 2.46 3.11 10 126.6% Lowest Price 3.99 3.99 13 100.0% Median MPR for Medicines With Minimum No. of Prices Comparisons of Median MPRs for Medicines With Prices in Both Sectors Reference Price Data Used = MSH 2003 Summary of Medicines Availability and Median MPR by Product Type Includes Core Medicines Only (n=30 on list) Includes Core Medicines Only (n=30 on list) Reference Price Data Used = MSH 2003 Median Percent Availability No. of Products With Minimum No. of Prices Obtained 36 4.f. Medicines availability and price summary Medicine Name Core List (yes/no) Public (n=4) Private (n=25) Other (n=15) Public (n=4) Private (n=25) Other (n=15) Public (n=4) Private (n=25) Other (n=15) Aciclovir yes 0.0% 0.0% 0.0% 50.0% 32.0% 6.7% 100.0% 68.0% 46.7% Amitriptyline yes 0.0% 0.0% 0.0% 50.0% 24.0% 6.7% 100.0% 36.0% 53.3% Amoxicillin 250 yes 0.0% 0.0% 0.0% 0.0% 68.0% 40.0% 100.0% 100.0% 93.3% Ampicillin no 0.0% 0.0% 0.0% 0.0% 40.0% 26.7% 50.0% 80.0% 40.0% Atenolol yes 0.0% 0.0% 0.0% 0.0% 40.0% 20.0% 100.0% 80.0% 73.3% Beclometasone inhaler yes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.0% 13.3% Captopril yes 0.0% 0.0% 0.0% 25.0% 76.0% 33.3% 100.0% 100.0% 93.3% Carbamazepine yes 0.0% 0.0% 0.0% 0.0% 48.0% 20.0% 100.0% 80.0% 86.7% Ceftriaxone injection 250mg no 0.0% 16.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.0% 0.0% Cephalexin 250 no 0.0% 0.0% 0.0% 100.0% 12.0% 13.3% 100.0% 12.0% 13.3% Chloramphenicol no 0.0% 0.0% 0.0% 25.0% 76.0% 66.7% 75.0% 100.0% 100.0% Ciprofloxacin yes 0.0% 0.0% 0.0% 50.0% 68.0% 26.7% 75.0% 80.0% 40.0% Clotrimazole pessary no 0.0% 0.0% 0.0% 100.0% 84.0% 86.7% 100.0% 100.0% 100.0% Co-trimoxazole suspension yes 0.0% 0.0% 0.0% 0.0% 32.0% 0.0% 0.0% 32.0% 0.0% Diazepam yes 0.0% 0.0% 0.0% 50.0% 8.0% 33.3% 75.0% 20.0% 80.0% Diclofenac 25 yes 0.0% 0.0% 0.0% 25.0% 36.0% 33.3% 100.0% 72.0% 73.3% Erythromycin 250 no 0.0% 0.0% 0.0% 25.0% 48.0% 26.7% 100.0% 96.0% 93.3% Fluconazole 150 no 0.0% 0.0% 0.0% 0.0% 24.0% 0.0% 0.0% 24.0% 0.0% Fluphenazine injection yes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Furosemide no 0.0% 0.0% 0.0% 0.0% 96.0% 73.3% 100.0% 100.0% 100.0% Gentamicin injection no 0.0% 0.0% 0.0% 25.0% 64.0% 53.3% 100.0% 96.0% 86.7% Glibenclamide yes 0.0% 0.0% 0.0% 50.0% 44.0% 0.0% 75.0% 44.0% 0.0% Hydrochlorothiazide yes 0.0% 0.0% 0.0% 0.0% 52.0% 33.3% 75.0% 52.0% 60.0% Ibuprofen no 0.0% 0.0% 0.0% 25.0% 68.0% 26.7% 50.0% 84.0% 60.0% Indomethacin no 0.0% 0.0% 0.0% 50.0% 80.0% 73.3% 100.0% 100.0% 93.3% Mebendazole no 0.0% 0.0% 0.0% 0.0% 32.0% 6.7% 100.0% 92.0% 93.3% Metformin yes 0.0% 0.0% 0.0% 25.0% 20.0% 6.7% 50.0% 20.0% 6.7% Metronidazole 250 no 0.0% 0.0% 0.0% 0.0% 60.0% 46.7% 100.0% 100.0% 100.0% Omeprazole yes 0.0% 0.0% 0.0% 0.0% 52.0% 26.7% 100.0% 80.0% 80.0% Propranolol no 0.0% 0.0% 0.0% 50.0% 88.0% 66.7% 100.0% 96.0% 93.3% Ranitidine yes 0.0% 0.0% 0.0% 0.0% 48.0% 40.0% 100.0% 88.0% 86.7% Reserpine no 0.0% 0.0% 0.0% 75.0% 24.0% 46.7% 75.0% 24.0% 46.7% Salbutamol inhaler yes 0.0% 4.0% 0.0% 0.0% 40.0% 20.0% 100.0% 60.0% 46.7% Brand Lowest PriceMost Sold Medicines Availability in Outlets 37 Medicine Name Core List (yes/no) Procure ment (n=8) Public (n=4) Private (n=25) Other (n=15) Procure ment (n=8) Public (n=4) Private (n=25) Other (n=15) Procure ment (n=8) Public (n=4) Private (n=25) Other (n=15) Aciclovir yes 1.92 1.30 1.38 2.35 1.50 Amitriptyline yes 5.24 8.18 5.24 5.52 7.63 5.81 Amoxicillin 250 yes 2.03 2.89 2.41 1.95 2.60 2.89 2.89 Ampicillin no 1.45 1.93 1.83 1.26 1.93 1.93 Atenolol yes 3.07 8.17 4.29 3.93 7.57 7.13 Beclometasone inhaler yes Captopril yes 1.41 2.82 1.63 1.58 2.89 2.82 2.35 Carbamazepine yes 2.29 3.54 1.94 1.92 3.33 3.33 Ceftriaxone injection 250mg no 6.40 5.08 Cephalexin 250 no 0.79 0.79 Chloramphenicol no 0.65 1.02 1.02 0.61 1.02 1.02 Ciprofloxacin yes 2.50 6.51 6.25 2.50 6.51 6.51 Clotrimazole pessary no 3.82 4.17 4.17 2.50 3.82 4.17 4.17 Co-trimoxazole suspension yes 8.63 8.63 Diazepam yes 8.88 9.47 8.58 11.84 9.47 Diclofenac 25 yes 8.93 13.00 16.25 8.93 10.56 11.78 13.00 Erythromycin 250 no 2.12 2.67 2.31 1.90 2.03 2.54 2.44 Fluconazole 150 no 120.13 120.13 Fluphenazine injection yes Furosemide no 1.73 2.59 2.76 1.73 2.07 2.59 2.76 Gentamicin injection no 1.23 2.30 2.15 1.44 1.97 2.49 2.24 Glibenclamide yes 5.05 7.58 5.15 7.58 Hydrochlorothiazide yes 24.14 30.77 23.67 24.14 30.77 18.94 Ibuprofen no 4.39 7.80 7.80 4.56 7.80 7.80 Indomethacin no 3.33 4.76 4.76 3.33 4.98 4.76 4.76 Mebendazole no 33.68 40.41 55.06 26.94 40.41 Metformin yes 2.93 3.72 2.93 3.72 Metronidazole 250 no 3.69 6.72 6.72 3.69 5.13 6.72 6.27 Omeprazole yes 0.59 0.99 0.95 0.64 0.85 0.99 0.75 Propranolol no 3.90 7.31 8.12 3.57 4.47 6.50 7.72 Ranitidine yes 2.18 4.08 3.99 2.08 2.31 3.99 3.99 Reserpine no 0.59 0.75 0.79 0.59 0.75 0.79 Salbutamol inhaler yes 1.08 1.28 1.08 1.13 1.20 0.94 Most Sold Medicines Median Price Ratios (MPRs) in Procurements and Outlets Brand Lowest Price (Reference Price Data Used = MSH 2003) 38 Affordability summary 2292.9 Diabetes Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Glibenclamide 5 mg cap/tab 30 60 Brand Most Sold 1500.00 0.7 2250.00 1.0 Lowest Price 1530.00 0.7 2250.00 1.0 Hypertension Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Hydrochlorothiazide 25 mg cap/tab 30 30 Brand Most Sold 3059.40 1.3 3900.00 1.7 3000.00 1.3 Lowest Price 3059.40 1.3 3900.00 1.7 2400.00 1.0 Hypertension Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Atenolol 50 mg cap/tab 30 30 Brand Most Sold 1035.00 0.5 2750.00 1.2 Lowest Price 1443.00 0.6 1325.00 0.6 2550.00 1.1 2400.00 1.0 Adult resp. infects. Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Amoxicillin 250 250 mg cap/tab 7 21 Brand Most Sold 883.05 0.4 1260.00 0.5 1050.00 0.5 Lowest Price 850.50 0.4 1134.00 0.5 1260.00 0.5 1260.00 0.5 Pediatric resp. infecs. Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Co-trimoxazole suspension 8+40 mg/ml millilitre 7 70 Brand Most Sold 2625.00 1.1 Lowest Price 2625.00 1.1 Gonorrhoea Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Ciprofloxacin 500 mg cap/tab 1 1 Brand Most Sold 95.85 0.0 250.00 0.1 240.00 0.1 Lowest Price 95.85 0.0 250.00 0.1 250.00 0.1 Arthritis Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Diclofenac 25 25 mg cap/tab 30 60 Brand Most Sold 3300.00 1.4 4800.00 2.1 6000.00 2.6 Lowest Price 3300.00 1.4 3900.00 1.7 4350.00 1.9 4800.00 2.1 Depression Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Amitriptyline 25 mg cap/tab 30 90 Brand Most Sold 4323.60 1.9 6750.00 2.9 Lowest Price 4323.60 1.9 4554.00 2.0 6300.00 2.7 4797.00 2.1 Asthma Select Medicine Name Medicine Strength Dosage Form Treatment Duration (in Days) Total # of Units per Treatment Product Type Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Median Treatment Price Days' Wages Salbutamol inhaler 0.1 mg/dose dose as needed 200 Brand Private Retail Other Patient Public Procurement Daily wage of lowest paid government worker (in local currency): Public Procurement Public Procurement Public Procurement Other PatientPublic Patient Private Retail Public Patient Private Retail Other Patient Public Patient Public Procurement Public Patient Private Retail Other Patient Public Patient Private Retail Other Patient Public Procurement Public Patient Private Retail Other Patient Public Procurement Public Patient Private Retail Other Patient Public Procurement Public Patient Private Retail Other Patient Public Procurement Public Patient Private Retail Other Patient 39 Cumulative mark-up and price composition sheet Describe sector and type of medicine: Public sector procurement, most sold generic version of locally produced amoxicillin Example 1:Medicine Name Medicine Strength Dosage Form Target Pack Size Disp Type of Charge Charge Basis Amount of Charge Price of Dispensed Quantity Cumulative % Mark-up Amoxicillin 250 mg cap/tab 21 21 MSP NA NA 260,00 0,00% Wholesale mark-up percent 15% 299,00 15,00% Value Added Tax (VAT) percent 15% 343,85 32,25% Describe sector and type of medicine: Private sector, most sold generic version of imported omeprazole Example 2:Medicine Name Medicine Strength Dosage Form Target Pack Size Disp Type of Charge Charge Basis Amount of Charge Price of Dispensed Quantity Cumulative % Mark-up Omeprazole 20 mg cap/tab 30 30 CIF NA NA 3600,00 0,00% Customs duty percent 5% 3780,00 5,00% Stamp duty percent 1% 3817,80 6,05% Wholesale mark-up percent 25% 4772,25 32,56% Retail mark -up percent 30% 6203,93 72,33% VAT percent 15% 7134,51 98,18% ` Describe sector and type of medicine: Private sector, innovator brand version of imported ceftriaxone injection Example 3:Medicine Name Medicine Strength Dosage Form Target Pack Size Disp Type of Charge Charge Basis Amount of Charge Price of Dispensed Quantity Cumulative % Mark-up Ceftriaxone 250 mg/vial vial 1 1 CIF NA NA 5100,00 0,00% Customs duty percent 5% 5355,00 5,00% Stamp duty percent 1% 5408,55 6,05% Wholesale mark -up percent 25% 6760,69 32,56% Retail mark -up percent 10% 7436,76 45,82% VAT percent 15% 8552,27 67,69% 40 Annex 5: Medicines data collection form used for survey Medicine Price Data Collection form Use one form for each health facility and pharmacy Date: Area number: Name of town/village/district: Name of health facility/pharmacy (optional): Health facility/pharmacy ID (mandatory): Distance in km from nearest town (population >50 000): Type of health facility:  Public  Private retail pharmacy  Other (please specify): Type of price in public and private not-for-profit sector:  Procurement price  Price the patient pays Name of manager of the facility: Name of person(s) who provided information on medicine prices and availability (if different): Data collectors: Verification To be completed by the area supervisor at the end of the day Signed: Date: 41 MEDICINE PRICE DATA COLLECTION FORM Most sold: determined nationally Lowest price: determined at facility A B C D E F G H I Generic name, dosage form, strength Brand name(s) Manufacturer Available tick  for yes Pack size recom- mended Pack size found Price of pack found Unit price (4 digits) Comments Aciclovir tab 200 mg Zovirax GSK 25 /òàá Most sold generic equivalent Acilovira Ferein 25 Lowest price generic equivalent 25 Amitriptyline tab 25 mg Tryptizol MSD 100 /tab Most sold generic equivalent Amitriptylino 25 Enddokrininiai 100 Lowest price generic equivalent 100 Amoxicillin caps/tab 250 mg Amoxil SKB (GSK) 21 /tab Most sold generic equivalent Philco amoxy Phylco Pharma 21 Lowest price generic equivalent 21 Ampicillin tab 500 mg Pentrexyl BMS 10 /tab Most sold generic equivalent Philcoampi Philco Pharma 10 Lowest price generic equivalent 10 Atenolol tab 50 mg Tenormin AstraZeneca 60 /tab Most sold generic equivalent Atenolol Akri Akrikhin 60 Lowest price generic equivalent 60 Beclometasone inhaler 50 mcg/ dose Becotide GSK 1 inhaler: 200 doses /dose Most sold generic equivalent Becotide GSK 1 inhaler: 200 doses Lowest price generic equivalent 1 inhaler: 200 doses Gentamycin inj. 40 mg/ml Garamycin Schering corp 2 ml /ml Most sold generic equivalent Philco genta80 Philco Pharma 2ml Lowest price generic equivalent 2ml Hydrochlorothiazide tab 25 mg Dichlotride MSD 20 /tab Most sold generic equivalent Hypothiazid Sanofi-Synthelabo 20 Lowest price generic equivalent 20 42 Glibenclamide tab 5 mg Daonil HMR 60 /tab Most sold generic equivalent Mannil -5 Berlinkhemie 60 Lowest price generic equivalent 60 Diazepam tab 5 mg Valium Roche 100 /tab Most sold generic equivalent Diazepam Laboratorio Farmacologico Milanes25 100 Lowest price generic equivalent 100 Diclofenac tab 25 mg Voltaren Novartis 28 /tab Most sold generic equivalent Diclodenk Denkpharm 28 Lowest price generic equivalent 28 Ibuprofen tab 400 mg Brufen Knoll 20 /tab Most sold generic equivalent Lemprofen 400 Hans E Lembcke 20 Lowest price generic equivalent 20 Indometacin tab 25 mg Indocid MSD 10 /tab Most sold generic equivalent Indomon Monos Pharm 10 Lowest price generic equivalent 10 Captopril tab 25 mg Capoten BMS 60 /tab Most sold generic equivalent Lemcapril 25 Hans E Lembcke 60 Lowest price generic equivalent 60 Carbamazepine tab 200 mg Tegretol Novartis 100 /tab Most sold generic equivalent Convulem-200 Hans E Lembcke 100 Lowest price generic equivalent Clotrimazol supp.(vag) 100 mg Canesten Bayer 21 /tab Most sold generic equivalent Lemnesten 100 Hans E Lembcke 21 Lowest price generic equivalent 21 Co-trimoxazole paed suspension (8+40) mg/ml Bactrim Roche 100 ml /ml Most sold generic equivalent Letrim-2880 Hans E Lembcke 100 ml Lowest price generic equivalent 100 ml Mebendazol tab 100 mg Vermox Janssen 6 /tab Most sold generic equivalent Mebendazol Hans E Lembcke 6 Lowest price generic equivalent 6 Metronidazole tab 250 mg Flagyl Phone Poulenc 20 /tab 43 Most sold generic equivalent Philco-Metro 250 Philco Pharma 20 Lowest price generic equivalent 20 Metformin tab 500 mg Glucophage Merck 100 /tab Most sold generic equivalent Metformin Denk 500 Denk pharma 100 Lowest price generic equivalent 100 Nifedipine Retard tab 10 mg Adalat Retard Bayer 10 /tab Most sold generic equivalent Nifedipine Denk 10 retard Denk pharma 10 Lowest price generic equivalent 10 Omeprazole caps 20 mg Losec AstraZeneca 30 /caps Most sold generic equivalent Lemloc-20 Hans E Lembcke 30 Lowest price generic equivalent 30 Propranolol tab 40 mg Inderal Astra Zeneca 20 /tab Most sold generic equivalent Propranolol Balkanpharma 20 Lowest price generic equivalent 20 Ranitidine tab 150 mg Zantac GSK 60 /tab Most sold generic equivalent Kalamtac Hans E Lembcke 60 Lowest price generic equivalent 60 Reserpine tab 250 mcg Serpasil Biochemie (former Ciba) 100 /tab Most sold generic equivalent Reserpine Oterop 100 Lowest price generic equivalent 100 Salbutamol inhaler 0.1 mg per dose Ventoline GSK 1 inhaler: 200 doses /dose Most sold generic equivalent Salbutamol Moskhimpharm prepatai 1 inhaler: 200 doses Lowest price generic equivalent 1 inhaler: 200 doses Fluconazole caps/tab 150 mg Diflucan Pfizer 30 /tab Most sold generic equivalent Diflazon KRKA 30 Lowest price generic equivalent 30 Fluphenazine decanoate inj 25 mg/ml Modecate Sanofi-Winthrop/ BMS 1 ampoule /ml Most sold generic equivalent Fluphenazine decanoate Rotex Medica 1 ampoule 44 Lowest price generic equivalent 1 ampoule Furosemide tab 40 mg Lasix Hoechst 10 /tab Most sold generic equivalent Furosemid Monos Pharm 10 Lowest price generic equivalent 10 Chloramphenicol tab 500 mg Chloromycetin Parke Davis or Pfizer 10 /tab Most sold generic equivalent Chloramphenicol Monos Pharm 10 Lowest price generic equivalent 10 Cephalexin tab 250 mg Keflex Lilly 10 /tab Most sold generic equivalent Ospexin Biochemie 10 Lowest price generic equivalent 10 Ceftriaxone inj 250 mg powder Rocephin Roche 1 vial /vial Most sold generic equivalent Rocephin Roche 1 vial Lowest price generic equivalent 1 vial Ciprofloxacin tab 500 mg Ciproxin Bayer 1 /tab Most sold generic equivalent Philco-Cipro Philco Pharma 1 Lowest price generic equivalent 1 Eritromycin tab 250 mg Erythrocin Abbott 10 /tab Most sold generic equivalent Eritromycin Syntez 10 Lowest price generic equivalent 10 45 Annex 6: National Pharmaceutical Sector Form, Mongolia Date: 12 August, 2004 Population: 2’476’644 Daily wage of lowest paid government worker 2292.9 ¥ Rate of exchange (commercial “buy” rate) to US dollars on the first day of data collection: 1 US$=1195 ¥ (tugrug) Sources of information: 1. “Adoption of the Government Policy on Drugs”, Mongolian Parliament Resolution #68, 2002; 2. “To renewal of the Essential Drug List”, Health Minister’s Order #168, 2001; 3. “Rule of procurement of pharmaceuticals”, Order of Health Minister and Minister of Finance and Economics # 01/06, 2002; 4. “Regulation on State Drug Registration”, Health Minister’s order # 177, 2003; 5. “Reimbursement of Drug from Health Insurance Fund”, Resolution of Subcouncil of Health Insurance, National Council of Public Insurance # 03, 2002; 6. “Resolution on Salary of Government Officers” Government Resolution # 42, 2004 7. Information data of Directorate of Medical Services (Government Executing Agency, MOH); 8. Data, National Statistical Office, 2003; 9. “Out of pocket survey”, National Statistical Office, 2002 10. Health Statistic, MOH, 2003; 11. National Health Accounts, Preliminary estimations, 2003 12. Annual report, State Social Insurance General Office, 2003 13. Currency exchange rate (9.8.2004), Mongol Bank ; General information on the pharmaceutical sector Is there a formal National Medicines Policy document covering both the public and private sectors?  Yes  No Is an Essential Medicines List (EML) available?  Yes  No If yes, state total number of medicines on national EML: If yes, year of last revision: 2001 If yes, is it (tick all that apply):  National  Regional  Public sector only  Both public and private sectors  Other (please specify): 46 If yes, is the EML being used (tick all that apply):  For registration of medicines nationally  Public sector procurement only  Insurance and/or reimbursement schemes  Private sector  Public sector Is there a policy for generic prescribing or substitution?  Yes  No Are there incentives for generic prescribing or substitution?  Yes  No Public procurement3 Is procurement in the public sector limited to a selection of essential medicines?  Yes  No If no, please specify if any other limitation is in force: Type of public sector procurement (tick all that apply):  International, competitive tender  Open  Closed (restricted)  National, competitive tender  Open  Closed (restricted)  Negotiation/direct purchasing Are the products purchased all registered?  Yes  No Is there a local preference?4  Yes  No Are there public health programmes fully implemented by donor  Yes  No assistance which also provide medicines? (e.g. TB, family planning, etc.) If yes, please specify: TB, family planning, STD, IMCI. Distribution5 Is there a public sector distribution centre/warehouse?  Yes  No If yes, specify levels: There is a state drug wholesaler. It is joint stock company with 51% of shares owned by state. Are there private not-for-profit distribution centres:  Yes  No e.g. missions/nongovernmental organizations? If yes, please specify: Number of licensed wholesalers: 50 Retail Urban Rural Overall 3 If there is a public procurement system, there is usually a limited list of items that can be procured. Products procured on international tenders are sometimes registered in the recipient country only by generic names. Import permits to named suppliers are issued based on the approved list of tender awards. An open tender is one that is publicly announced; a closed one is sent to a selection of approved suppliers. 4 A local preference means that local companies will be preferred even if their prices are not the cheapest. Local preference is normally in the range of 10–20%. 5 The public sector often has a central storage and distribution centre which may have at least one sublevel. The private not-for-profit sector may be dominated by one type of NGO (e.g. church missions), but may also comprise others such as Bamako Initiative type projects, Red Cross or Red Crescent Society, Médecins Sans Frontières. 47 Number of inhabitants per pharmacy (approx.) 4776.8 2472.2 3420.8 Number of inhabitants per qualified pharmacist (approx.) 2690.9 42125.7 4470.5 Number of pharmacies with qualified pharmacists 403 25 428 Number of medicine outlets with pharmacy technician 293 431 724 Number of other licensed medicine outlets - - - Private sector6 Are there independent pharmacies?  Yes  No Number: no data Are there chain pharmacies?  Yes  No Number: no data Do doctors dispense medicines?7  Yes  No If yes, approximate coverage or % of doctors who dispense: Are there pharmacies or medicine outlets in health facilities?  Yes  No Financing (Give approximate figures, converted to US dollars at current exchange rate: commercial “buy” rate on the first day of data collection) Type of expenditure Approximate annual budget(US dollars) National public expenditure on medicines including government insurance, military, local purchases in past year 8,445.29 million Estimated total private medicine expenditure in past year (out of pocket, private insurance, NGO/mission) 8,648.53 million Total value of international medicine aid or donations in past year 920 thousand What percentage of medicines by value are imported? 0.97 % Government price policy Is there a medicines regulatory authority?  Yes  No Is pricing regulated?  Yes  No Is setting prices part of market authorization/registration?  Yes  No Do registration fees differ between:  Innovator brand and generic equivalents  Yes  No  Imported and locally produced medicines  Yes  No Public sector Are there margins (mark-ups) in the distribution chain?  Yes  No  Central medical stores 10 %  Regional store 15 %  Other store (specify) 0 %  Public medicine outlet 10 % Are there any other fees or levies?  Yes  No If yes, please describe: 6 Retail outlets may be called pharmacies, medicine outlets, drug stores, chemists, etc. They may be run/owned by a qualified pharmacist (with diploma) or another category: e.g. pharmacy technician, or a lay person with short training. 7 Many countries allow doctors to dispense and sell medicines. 48 Private retail sector Are there maximum profit margins?  Yes  No If yes (if they vary, give maximum and minimum):  Wholesale %  Retail % Is there a maximum retail price (sales price)?  Yes  No (If it varies, give maximum and minimum)  Maximum:  Minimum: Do patients pay professional fees (e.g. dispensing fee)?  Yes  No If yes, please describe: “Other” sector Are there maximum profit margins?  Yes  No If yes (if they vary, give maximum and minimum):  Wholesale %  Retail % Is there a maximum sales price?  Yes  No Insurance, risk-sharing or prepayment schemes Are there any health insurance, risk-sharing or  Yes  No prepayment schemes or revolving medicine funds? If yes, please describe: Social Health Insurance Skim-Compulsory for all. Are all medicines covered?  Yes  No If no, state which medicines are covered (e.g. EML, public health programmes): Health insurance covers 105 items of essential medicines. Are some patients / groups of patients exempted, regardless of insurance coverage? (e.g. children < X yrs, war veterans)  Yes  No If yes, please specify: Estimated percentage of population covered 76.6 % (by the end of 2003) Is it official policy to supply all medicines free at primary health care level?  Yes  No If no, are some free?  Yes  No If yes, tick all that apply:  Tuberculosis  Malaria  Oral rehydration salts  Family planning  Others, please specify: Are there official user charges/patient co-payments/fees?  Yes  No Are all medicines supplied free at hospitals?  Yes  No 49 If no, are some free?  Yes  No If yes, please specify: Inpatient cases and some outpatients. Retail Urban Rural Overall Number of inhabitants per pharmacy (approx.) 1423501/ 298=4776 .8 1053143/ 426=2472 .2 2476644/ 724=3420 .8 Number of inhabitants per qualified pharmacist (approx.) 1423501/ 529=2690 .9 1053143/ 25=42125 .7 2476644/ 554=4470 .5 Number of pharmacies with qualified pharmacists 403 25 428 Number of medicine outlets with pharmacy technician 688 243 931 Number of other licensed medicine outlets no no no 50 2. METHODOLOGY 4.5. Inter-sector patient prices and availability comparisons 1. INTRODUCTION AND BACKGROUND Table 2 Drug allocation in the health budget Table 3 The key indicators (2004) 2. METHODology Table 5 Core medicines removed Table 6 Supplementary medicines added 4.5 Inter-sector patient prices and availability comparisons (Annex 4e) Annex 1: List of medicines surveyed (Product Table) Annex 2: List of essential medicines Annex 3: Timetable of survey Annex 4: Analysis summary sheets 4. a. Public sector - procurement prices 4.b. Public sector - patient prices 4.c. Private sector pharmacies – patient prices 4.d. RDF pharmacies (‘Other’ sector) – patient prices Cumulative mark-up and price composition sheet Annex 5: Medicines data collection form used for survey Medicine Price Data Collection form Use one form for each health facility and pharmacy Verification MEDICINE PRICE DATA COLLECTION FORM Annex 6: National Pharmaceutical Sector Form, Mongolia General information on the pharmaceutical sector Distribution5 Retail Private sector6 Financing Government price policy Public sector Private retail sector “Other” sector Insurance, risk-sharing or prepayment schemes Retail

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