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[afro-nets] Worldwide survey on the actual cost of medicines

Not everyone has access to medicines and not all medicines are available in the 
public sector. Medical reimbursement schemes are too expensive for most 
patients. What are the consequences? Pay for medicines at their full price in 
the private sector, purchase just a fraction of the treatment course, or worse, 
be untreated. Sickness should never result in making such choices. For the 
millions of people living in the impoverished regions of the world, medicines 
cost the sky.

To illustrate the issue of high prices, Health Action International (HAI) 
undertook a one day global ‘snapshot’ of the price of ciprofloxacin, a 
commonly-used off-patent antibiotic. The ‘snapshots’ indicate the full retail 
price a patient pays at a pharmacy on that day.  Data were collected from 93 
countries. Individuals from HAI’s extended network collected the prices for 
both the originator brand product manufactured by Bayer and the lowest priced 
generic equivalent in the pharmacy. An interactive map is on HAI’s website 
(www.haiweb.org/medicineprices), indicating the price variations between the 
Bayer originator product and the generic product, for a 7 day treatment course 
(14 tablets) in US$ using the exchange rate of 30 November 2009.

In South East Asia, on average both the originator brand price (US$17.46) and 
the price of the lowest priced generic (US$1.19) were substantially less than 
prices in other regions. For example the originator brand was 16 times the 
price of the lowest priced generic (as found in Africa). A course of the 
originator brand varied in price from about US$57 in Malaysia to about US$2 in 
Nepal and India. Generic prices ranged from about US$32 in Australia to less 
than US$1 in Myanmar (US$0.42), Sri Lanka (US$0.57), Indonesia (US$0.66), Viet 
Nam (US$0.66) and Lao PDR (US$0.59).  Indonesia had the largest brand premium 
with the originator brand priced at over 47 times the price of the lowest 
priced generic. By contrast, in India the originator brand was only 30% more 
than the generic.

The variation in price across countries within each income level was greater 
for the originator brand compared to the generics. For example, in lower 
middle-income countries the originator brand price varied from US$2 to US$131 
whereas generics ranged from less than US$1 to US$27. Generic ciprofloxacin is 
available at much lower prices than the originator brand product. In many 
countries, the price of the generic versions could be much lower and more 
affordable.

To improve treatment affordability, interventions are needed to *increase the 
use of low priced generics*. Governments need to ensure only good quality 
medicines are on the market and mandate generic substitution and create 
incentives for the dispensing of low priced generics. Sickness cure should not 
cost the sky.

*Please refer to HAI website to see the interactive map reporting the price 
data, and the analysis of results and recommendations: **
http://www.haiweb.org/medicineprices* <http://www.haiweb.org/medicineprices>
*. **For further information, contact Marg Ewen at HAI Global (telephone:
+31206833684 or e-mail: **medicineprices@haiweb.org*<medicineprices@haiweb.org> 
*) or Jinani Jayasekera at HAI Asia-Pacific (telephone: *

*Being sick and needing medicines is a costly misfortune in many countries*

When you are sick the price of a medicine matters – especially if you are one 
of the millions of people living in poverty in many countries around the world. 
Medicines are inaccessible for many people; they are either unavailable in the 
public sector, or patients cannot afford to be covered by a medical 
reimbursement scheme. People who face this dilemma are either forced to 
purchase medicines at full price in the private sector, go without, or buy a 
partial course of treatment.

To illustrate the issue of high prices, Health Action International (HAI) 
undertook a one day global ‘snapshot’ of the price of ciprofloxacin. 
Ciprofloxacin is a broad spectrum antibacterial used to treat various common 
infections, with a usual adult dose of 250-750mg twice daily for up to 14 days. 
The medicine has been off-patent in the US, Europe and elsewhere for at least 
than 5 years and numerous generic versions are manufactured throughout the 
world.

Individuals from HAI’s extended network collected the price which a patient 
would have to pay if they paid the full price (as opposed to a co-payment 
amount where reimbursement systems exist) for ciprofloxacin 500mg tablets in 
their nearest private retail pharmacy on 30 November 2009. Prices were 
collected for both the originator brand product manufactured by Bayer and the 
lowest priced generic equivalent in the pharmacy.

Below is shown the price for a 7 day treatment course (14 tablets) in US$ using 
the exchange rate of 30 November 2009 for the Bayer originator product in each 
location where data was collected - the larger the ‘bubble’, the higher the 
price.  An interactive form of this map is on HAI’s website ( 
www.haiweb.org/medicineprices), where prices of the lowest priced generics can 
also be viewed. These prices should not be considered representative of the 
situation in a given country, since great price variation exists within some 
countries, and they only report the final stage of the supply chain. However, 
they are indicative of what patients would have to pay, if paying the full 
retail price, in those pharmacies on that day.

The price a patient would pay for a course of the originator brand product in 
the private sector was highest in Colombia at more than 200 times the price in 
5 Asian countries where the price of generics was lowest – a difference of 
almost 20,000%.

 *Prices in the South East Asia region are much lower than in other regions *

As shown in the chart, the average price a patient would pay for a course of 
treatment with ciprofloxacin varies greatly across regions. In the South East 
Asia region, both the originator brand price (US$17.46) and the price of the 
lowest priced generic (US$1.19) were substantially less than prices in other 
regions.

In the South East Asia region, the originator brand was 16 times the price of 
the lowest priced generic (as found in Africa). In other regions, the 
originator brand was about 11-14 times the price of the lowest priced generic.

 *Prices vary greatly within the region*

Prices in countries within the region were also highly variable; the chart 
shows average prices for the originator brand and lowest price generics in 
countries in South East Asia and the Western Pacific region. The price for a 
course of treatment varied from US$57.12 in Malaysia (originator brand) to 
US$0.42 in Myanmar (generic).

A course of the originator brand varied in price from about US$57 in Malaysia 
to about US$2 in Nepal and India. Generic prices ranged from about US$32 in 
Australia to less than US1 in Myanmar (US$0.42), Sri Lanka (US$0.57), Indonesia 
(US$0.66), Viet Nam (US$0.66) and Lao PDR (US$0.59). Indonesia had the largest 
brand premium with the originator brand priced at over 47 times the price of 
the lowest priced genericvii. By contrast, in India the originator brand was 
only 30% more than the generic.

*Inequitable pricing –originator brand price is unrelated to the income level 
of the country*

The chart below shows the price a patient would pay for a course of treatment 
in countries grouped by World Bank income level. For the originator brand (OB), 
the average price (indicated in red) showed very little variation across the 
different income levels. A different picture is seen for lowest priced generics 
(LPG) where the average price (also indicated in red) decreased as the wealth 
of the country decreased (from about US$ 20 in high income countries to about 
US$ 3 in low income countries).

The variation in price across countries within each income level was greater 
for the originator brand compared to the generics. For example, in lower 
middle-income countries the originator brand price varied from US$ 2 to US$ 131 
whereas generics ranged from less than US$ 1 to US$ 27.

*Purchasing power: ciprofloxacin can be considered as expensive in many 
countries*

Since theoretically currencies should trade at the rate that would make the 
price of goods the same in each country, purchasing power is a good indicator 
of how expensive goods are. Where the price in terms of purchasing-power parity 
is greater than the price at market exchange rates, the goods can be considered 
as expensive in that country. Likewise where the price in terms of 
purchasing-power parity is less than the price at market exchange rates, the 
goods can be considered to be low priced.

The price for the originator brand in Kyrgyzstan was extremely high at US$ 248 
at purchasing-power parity (and a much lower price at market exchange rates), 
whereas it was low in France at only US$ 28 (with a similar price at market 
rates), illustrating that in some countries the prices are too high.

Similarly for generics, the prices at purchasing-power parity were expensive in 
a number of countries. In Guatemala, the price of a course of a generic was 
high, at US$ 51 at purchasing power parity (and U$28 at market exchange rates), 
while the reverse applied in Switzerland.

 *Conclusions*

   - Generic ciprofloxacin is available at much lower prices than the 
originator brand product
   - In many countries, the price of the generic versions could be much lower 
and more affordable
   - The average price for the Bayer originator brand product was consistent 
across countries of different income levels

*Recommendations*

To improve treatment affordability, interventions are needed to *increase the 
use of low priced generics*. Governments need to:

   - Ensure only good quality medicines are on the market
   - Mandate generic substitution and create incentives for the dispensing of 
low priced generics
   - Ensure the public has easy access to information about the price they 
should pay for a medicine
   - Encourage active involvement of consumer and health professional 
organisations in education initiatives about the use of generic medicines
   - Remove taxes and duties on medicines, and regulate margins in the supply 
chain

For patients who cannot afford even the lowest priced generics purchased in the 
private sector, governments must provide essential medicines free of charge in 
the public sector, and ensure adequate financing and efficient supply systems 
to prevent stock-outs.

This snapshot of the price of ciprofloxacin is useful in illustrating prices 
across the world. However, governments need to continuously monitor prices, as 
well as availability and affordability, in various sectors and regions within 
their country. More important is to act on the findings to develop policies and 
strategies to improve medicine affordability and availability, monitor the 
outcomes and adapt to the continuously changing environment.

WHO/HAI has a tool available to survey medicine prices and availability, and is 
developing in-depth reviews on pricing policy options (see 
www.haiweb.org/medicineprices).

--
Meghana Bahar 
mailto:meghana@haiap.org

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