MALARIA: AFMm: Are medications truly affordable?

 Bill Brieger : 22 May 2011
Reporting from Nairobi, Inter Press Service (IPS) documents the experience of James Odhiambo who “goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund’s logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.” James finds what he needs at the sixth shop.
Without subsidy from the Affordable Medicines Facility malaria (AMFm), these drugs would cost about $5 or two days salary. See the much sought after medicine packet in a photo on the right by Isaiah Esipisu of IPS.
IPS, on further investigation, attributed the scarcity of the subsidized malaria medicines to the low profit margin that pharmacies who agree to sell the medicines are officially allowed. While the actual price of the AMFm drugs should be $0.50 for adult and $0.12 for child doses, IPS learned form a science reporter of the Nation Media Group that, “Two months ago, we requested our reporters from different parts of the country, including rural areas, to check on retailing prices of the subsidised anti-malarial drugs. As a result, we discovered that pharmacists sold them at varying prices ranging from 80 KES (one dollar), to 240 KES (three dollars).”
IPS learned from a private pharmacist that if she sold the commercial variety of Coartem (the approved artemether-lumefantrine combination drug) she could make $2 profit. The AMFm drugs were permitted only about $0.15 profit. For this pharmacist, ” it would not make any economic … considering her costs of transporting it from the distributors, and other inputs.”
Apparently the Ministry of Health believes the problem can be solved through an “awareness campaign (that) will help consumers make an informed choice and enable them to seek outlets that sell the drugs at the right price.” The cost of transport around town seeking the correctly priced drugs may wind up to be more that the price of the drugs themselves.
AMFm is still a new program. The Global Fund explains that, “Following the Global Fund Board’s decisions on successful applications to Phase 1 in November 2009, grant amendments or new grant agreements have been signed with most AMFm Phase 1 countries and implementation has started in several countries. The first co-paid ACTs were delivered to Ghana and Kenya in August 2010.” Seven other pilot projects are in varying stages of implementation.
Nigeria started implementation of AMFm in March 2011. The Director of the National Malaria Control Program in Abuja hoped that the AMFm subsidies would help crowd out fake and substandard malaria drugs from the market by offering medicines at around $0.50 instead of the $6-8 prices per packet in shops. Ironically conversations with people responsible for a pre-pilot of sorts carried out under a previous GFATM grant in Nigeria identified similar attitudes about profitability by medicine shop keepers. Might Nigeria be heading down the same road as Kenya?
Word is still out on AFFm implementation in Ghana. So far the Ghana Health Service is touting the benefits of AMFm - the low costs, the savings to the national insurance scheme and the edging out of poor quality drugs from the market. Interestingly, none of the news emanating from implementing countries appear to address the need for proper diagnostics to reduce inappropriate use of the malaria medicines.
Fortunately the Global Fund is planning an evaluation of the AMFm experience. This will address availability, affordability, use and market share. AMFm is a grand experiment. We hope it is well enough designed from the start to test real life forces in the private sector. Arbitrarily suggesting profit margin is not the way to go, but in the end shop keepers and pharmacists will hold the day through their choice to participate and the prices they set. Whether these decisions will improve coverage with appropriate malaria medicines will eventually be known when this two-year pilot finishes. In the meantime it appears that some important operational lessons can and should be learned and applied NOW.
http://www.malariafreefuture.org/blog/?p=1210

MALARIA: Kenya: The cost of "affordable" medication

Isaiah Esipisu : 19 May 2011
Nairobi — On the streets of Nairobi, James Odhiambo goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund's logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.
He finally buys it from Nila Pharmacies along Accra Road - the sixth outlet he has visited this morning.
"My brother was yesterday evening diagnosed with malaria at a private clinic in Dandora suburb upon his arrival from a two week holiday in the lakeside city of Kisumu. That is why I have come to town to search for drugs," says Odhiambo holding a prescription from the Samaritan Health Clinic - where his brother was diagnosed.
However, Odhiambo says his brother could not buy anti-malarial drugs from the clinic where he was tested because the available drugs were expensive costing 400 Kenyan Shillings (KES) (five dollars). This is the average price of anti-malaria drugs in Kenya.
"We have always seen these subsidised drugs being advertised all over in the media. We were not going to waste the entire 400 KES - equivalent to two days' wages - on a similar dose," said Odhiambo, who works as a casual labourer in the city.
The drugs Odhiambo is referring to are subsidised through the Affordable Medicines Facility - malaria (AMFm). All drugs manufactured under the scheme have the logo of a green leaf. It is managed by the Global Fund with support from the United Nations, the UK Department for International Development and related donors.
Kenya was one of the very first countries in Africa to implement the scheme in August 2010, where a dose for an adult was supposed to retail at 40 KES or 50 cents, and a dose for children under the age of five would cost 10 KES.
However, many pharmacies across the country took advantage of the subsidy to maximise profits. "Two months ago, we requested our reporters from different parts of the country, including rural areas, to check on retailing prices of the subsidised anti-malarial drugs. As a result, we discovered that pharmacists sold them at varying prices ranging from 80 KES (one dollar), to 240 KES (three dollars)," says Gatonye Gathura, the chief science reporter at the Nation Media Group in Kenya.
A pharmacist at a private pharmacy in Buruburu Estates in Nairobi told IPS that she had to inflate the price simply because if she sold the drugs at the recommended retail price, it would not make any economic sense to her - considering her costs of transporting it from the distributors, and other inputs.
According to Harley's Ltd, the distributor of one of the brands recommended for subsidy, a dose for an adult should be sold to retailers for 26 KES (over 25 cents) to be sold to consumers at the recommended price of 40 KES (50 cents).
But like many other pharmacists, Linda Atieno's pharmacy did not stock the subsidised drugs. "If I sold a dose of unsubsidised Coartem drugs for example, I make a profit of up to 200 KES (over two dollars). This compares poorly with the profit I would make from a dose of the subsidised version of Coartem - which is 14 KES," she says.
In order to reduce instances where pharmacists are inflating the cost of the subsidised drugs, the Kenyan government has embarked on awareness campaigns through the media to inform Kenyans of the availability of the drugs, and the recommended prices per dose.
According to Dr John Logedi, the deputy program manager at the Division of Malaria Control, the awareness campaign will help consumers make an informed choice and enable them to seek outlets that sell the drugs at the right price.
Technically, the government of Kenya does not have control over drugs sold in pharmacies in the private sector because the pharmaceutical market in the country is based on 'a willing seller, willing buyer' concept.
So far, the subsidised drugs in Kenya are distributed through both the public and the private sector.
However, despite difficulties in searching for pharmacies that stock the subsidised drugs and sells them at the correct prices, Odhiambo admits that the subsidy program is a great relief to many people with a meagre income like his. "Most of us cannot afford the unsubsidised drugs that cost up to 600 KES (over seven dollars). The subsidy is therefore good news to most of us," he said.
In marginalised rural areas such as Turkana, private pharmacies are yet to begin stocking the subsidised drugs, despite the launch of the programme several months ago. "We have the subsidised drugs in public health centres within Turkana Central. But not in private pharmacies," said Dr Gilchrist Lokoel, the Turkana Central Medical Officer of Health at the Lodwar District Hospital.
Phase one of AMFm is already under implementation in nine pilots in eight countries. They include Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and Zanzibar) and Uganda.
http://allafrica.com/stories/printable/201105210027.html