Retail Drug Market and the Prices of Antimalarial Medicines in Enugu Urban, Southeast Nigeria: Implications for Affordability and Access to Artemisinin-based Combination TherapyEzenduka Charles1, Okonta Mathew2, Ekwunife Obinna2

1. Health Policy Research Group Department of Pharmacology & Therapeutics, College of Medicine, University of Nigeria Enugu Campus2. Department of Clinical Pharmacy & Pharmacy Management, Faculty of Pharmaceutical Sciences, University of Nigeria Nsukka.

Outline Introduction & BackgroundResearch questions & objectivesMethodology & study designsData collections and analysisFindings and discussionsConclusions and recommendations

Introduction and backgroundA supply side analysis of antimalarial market

from the private sectorPrivate sector in Nigeria is still responsible

for over 60% of healthcare provisionRetail market for drugs accounts for a

greater proportion of malaria treatment in Nigeria [Onwujekwe et al. 2009]

Study analysed the private retail market to identify opportunities for policy to improve malaria control

Part of a research on the economics of antimalarial medicines in Nigeria

Study questions & objectives What are the relative availabilities of

antimalarial medicines in the retail market in Nigeria?

At what prices are antimalarial medicines sold and what are the determinants of the final prices?

How affordable are the antimalarial drugs?

How do market characteristics impact on the prices and affordability of antimalarial drugs in Nigeria?

What is the role of government on the prices of antimalarial drugs?

Methodology & study designEconomic framework of structure-conduct-

performance was used to analyse the retail market, comprising pharmacies and PPMVs

Prices and availability were determined based on the WHO/HAI recommendations

38 out of 351 retail outlets in the urban city were sampled stratified by type and location

5 categories of antimalarials were selected for survey study based on reasonable criteria

Urban setting was selected to capture the private sector which is almost completely concentrated in the area

Data collection and analysisQuantitative and qualitative tools were used

to collect data for the analysisQualitative interviews assessed providers

behaviours and their determinants Quantitative survey was used to determine

availability and prices of selected drugsRetail audit measured quantities of selected

drugs sold, based on equivalent adult dosesMS. Excel and Stata were used to analyse

dataData were analysed by drug category outlet

type

Findings

Table 1.Prices and availabilities of antimalarial drugs

Prices (US$)

Drug %Availability (n=38)

%Pack sale(n= sample size) Median Lowest Highest

ACTs 97 35 (30) 5.23 1.83 7.52

SPs 100 40 (30) 0.78 0.33 1.31

Artesunate 100 15 (30) 1.96 1.63 2.61

Amodiaquin 100 6 (29) 0.92 0.78 1.31

Chloroquine 62 4 (20) 0.36 0.13 0.98

Findings & DiscussionsThere is a very wide range of antimalarial drugs in the

retail market with average of 10 brands in each outlet (at least 7 categories) with ACTs having the widest range

SPs are the most popular antimalarial agents available in every outlet and their use is highest in PPMVs largely based on self medication and low cost

ACTs are closely the second most popular antimalarial drugs with highest use,(57%) among pharmacies; and the most prescribed antimalarial agents by healthcare professionals

The use of monotherapy AS, AQ and CQ is very significant with implication for malaria resistance and quality of treatment

Findings & DiscussionsThere is a wide variation of the prices of antimalarial

medicines, $0.13 - $8.17 (median price $1.63)

ACTs are the most expensive antimalarial group with a median price of $5.23 at a range of $1.8 - $7.52; about 7 x the price of SP

3 to 5 days income will be required to treat a malaria case with an ACT in a country where over 50% live below $2 per day

The retail market is highly characterised by low concentration and high price competition limiting retail mark-up to about 20% of final price

Procurement cost contribute over 75% of final price with little or no government regulation making it a policy target for price reduction

Level of competition highly influenced by open market due to poor or lack of government control

Conclusions & RecommendationsRetail market significantly impacts on the prices and

affordability of antimalarial medicines in Nigeria, highly characterised by competition and poor regulation

Findings suggest SPs and ACTs as the dominant antimalarial agents but monotherapy with AS is very significant which may include combination with AQ in ACT

ACTs have become increasingly popular but limited in use by high costs making them unaffordable to majority of low income population who live below the poverty line

Results confirm that in many countries access to ACTs is limited by unaffordable prices in addition to limited information on their relative efficiency in malaria treatment

Conclusions & RecommendationsMore efforts are needed in making the ACTs the

drugs of choice in the treatment of malaria in Nigeria

As the major driver of high cost under high competition, procurement is a key target for price reduction to enhance affordability of ACTs in the country.

Government subsidised provision of drugs through the CMS could be expanded to include the private sector providers through the PPP

Regular training and update of retail providers and enhanced public enlightenment are required to increase the knowledge and use of ACTs in the country

Thank you all