Balasubramaniam R 1 , Beneragama BVSH 2 , Sri Ranganathan S 1

1. AVAILABILITY, PRICE AND AFFORDABILITY OF KEY ESSENTIAL MEDICINES FOR CHILDREN IN A RESOURCE LIMITED COUNTRYA NATIONAL SURVEY Balasubramaniam R 1, Beneragama BVSH 2, Sri Ranganathan S 1 Department of Pharmacology, Faculty of Medicine, University of Colombo, Sri Lanka Division of Medical Supplies and Technology, Ministry of Healthcare and Nutrition, Sri Lanka Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18, 2011

3. Methods

4. Domperidone oral liquid 5 mg/5ml (10 ml) Erythromycin oral liquid 125 mg/5 ml (100 ml) Ferrous salt oral liquid 30 mg/ml (250 ml) Ibuprofen oral liquid 100 mg/5ml (60 ml) Mebendazole Chewable tablet 100 mg (6 tablets) 18.Mebendazole oral liquid 100 mg/5 ml (30 ml) 19.Metronidazole 200 mg (tablet) 20.ORS Packet to make 1 litre of solution 21.Paracetamol oral liquid 120 mg/5 ml (60 ml) Paracetamol 500 mg (tablet) Salbutamol –MDI Inhaler 100 microgram /dose (200 doses) Salbutamol Respiratory solution 0.5% (15 ml) Vitamin C 100 mg (tablet) • Amoxicillin oral liquid 125 mg/5 ml (100ml) • Amoxicillin 250 mg (capsule/tablet) • Amoxicillin + clavulanic acid oral liquid 125 mg + 31.25 mg/5 ml (100 ml) • Beclometasone – MDI Inhaler 100 microgram/dose (200 doses) • Carbamazepine oral liquid 100 mg/5 ml (100 ml) • Ceftriaxone Injection 1 gram (vial) • Chlorphenamine oral liquid 2 mg/5 ml (100ml) • Clotrimazole Topical cream 1% (20g tube) • Cloxacillin oral liquid 125 mg/5 ml (100 ml) • Cotrimoxazole oral liquid 200 mg + 40 mg/5 ml (100 ml) • Diazepam Injection 5 mg/ml (2 ml ampoule) • DEC 50 mg (tablet)

5. Results – Availability Public sector • Mean per cent availability: • PH= 52% (range = 25-75, SD=14) • PP = 80% (range = 56-96, SD = 11) • ROSP - 88% (range76- 100, SD = 9.5) • Wide gap in the availability between public and private sector • Oral liquid dosage forms of anti infectives, carbamazepine, ferrous, domperidone, ibuprofen, paracetamol • Inhaled dosage forms of anti-asthmatics • Availability in public sector as good as to that of private sector • Oral solid dosage forms of amoxicillin, metronidazole, mebendazole (chewable), paracetamol, vitamin C, ORS, chlorphenamine syrup Private sector

6. Results – Price (PP + ROSP) • Lowest priced generics (LPG): 0.05-3.75 times IRP • Originators (OB): 0.23-20 times IRP • 75% of survey medicines: Prices of the LPG > IRP • Exception (25%) where Prices of LPG < IRP • Amoxicillin-clavulanic acid suspension • Diethylcarbamazine citrate • Mebendazole chewable tablet • Salbutamol MDI and respiratory solution • 15 medicines were available as both OB and LPG • Mean percent difference in price between OB and LPG of these medicines = 365% (range -21, 2343): • Price of OB < LPG only for ibuprofen syrup

7. Results – Affordability Bronchial Asthma Epilepsy One bottle (100 ml) of carbamazepine syrup (100 mg/ 5 ml) = 2.2 days’ wages for the LPUGW Carbamazepine 50 mg tds for one month= 5 days wage for the LPUGW • Salbutamol (100 µg/dose) and beclometasone (100 µg /dose) one inhaler each • 1.5 - 2.17 days’ wages for the LPUGW • Beclometasone 100 µg bd for 3 months = • 1 day wage for the LPUGW However, a fair amount of Sri Lankan population works in the unorganized sector with an average daily salary much lower than the daily salary of the LPUGW • LPUGW = Lowest paid unskilled government worker {daily wage 400/= (3.5 USD)}

9. Implications for implementing policies Immediate actions Long term actions Further studies are required Evidence obtained from these studies Interventions National policies Conduction of regular assessment surveys To study the impact of policy changes and interventions • Disseminating the results • Raising awareness: children need “better medicines” • Identifying key essential medicines for children (KEMc) expected to be available in different levels • Advocating for their sustained availability • Making KEMc as “Priority” medicines

10. Future research agenda • Poor availability in the public sector: could be due to shortcomings in the supply system or prescribing practices or in both • Further detailed studies are required to understand these two factors and determine the shortcomings • Variability in prices and wide gap observed between the prices of the OB and LPG in the private sector • Further detailed studies are required on pricing and price components of key essential medicines for children

11. Acknowledgments • WHO/Sri Lanka and South East Asian Regional Office (SEARO) for funding (SE SRL DDE RB 08 17.1.1) • Dr K Weerasuriya (WHO) and Mr. Martin Auton (HAI) for guidance and support • Ministry of Health and SPC authorities for approving the survey • Provincial Health authorities and hospital administrators for granting permission to collect data • Pharmacists in the respective survey settings for providing the data, Drs S A C Senadeera and R Thanikaivasan for assisting in data entry • Ms PriyaniPerera, Ms InokaGammune, Mr SupunPereraof the Department of Pharmacology, Faculty of Medicine, Colombo for secretarial assistance Where is my essential medicine?

12. References • Department of Census and Statistics Sri Lanka. Estimated mid year population by age and sex 2000-2010. Available from http://www.statistics.gov.lk. Accessed on 10th October 2011 • Ministry of Healthcare and Nutrition and Department of Pharmacology, Faculty of Medicine, University of Colombo. National list of Essential Medicines, Sri Lanka, 4th revision. Ministry of Healthcare and Nutrition and Department of Pharmacology, Faculty of Medicine, University of Colombo; 2009 • World Health Organization. The Selection of essential drugs. Report of the WHO Expert Committee. Technical Report Series No 615. Geneva: WHO; 1977 • United Nations Development Group. Indicators for Monitoring the Millennium Development Goals. United Nations: New York, 2003 • World Health Organization. Medicines: Medicines for children June 2010. Available from http://www.who.int/mediacentre/factsheets/fs341/en/index.html. accessed on 10th October 2011 • Health Action International and World Health Organization. Medicine prices, availability, affordability and price components, 2008. Available from http://www.haiweb.org/medicineprices/. Accessed on 10th January 2009 • Management Sciences for Health (MSH) International Drug Price Indicator Guide, 2008.Available from http://erc.msh.org. Accessed 10th October 2011 • Central Bank of Sri Lanka. Restructuring of Public Service Salaries of the Government of Sri Lanka Based on Budget Proposals -2006, No 6/ 2006 (April, 25, 2006) • World Health Organization. The selection and use of essential medicines. Report of the WHO Expert Committee, March 2009 (including the 2nd Model List of Essential Medicines for Children). Geneva: WHO; 2010 • Robertson J, Forte G, Trapsida JM, Hill S. What essential medicines for children are on the shelf? Bulletin of the World Health Organisation. 2009 Mar;87(3):231-7