Availability and affordability of priority life-saving medicines for under-five children in health facilities of Tigray region, northern Ethiopia

Being a critical improvement indicator of health, socioeconomic status and quality of life of a given population, there has been a global drive to improve the under-five children mortality rate during the past three decades [1]. To that end, over the past fifteen years, under-five global mortality rate has declined from 90.6 deaths per 1000 live births in 1990 to 42.5 in 2015 [2]. However, high rate remains in sub-Saharan Africa where one child in 12 dies before his or her fifth birthday – far higher than the average ratio of 1 in 147 in high-income countries [3]. In Ethiopia, children under-five mortality rate was reported to be 67 per 1000 live births in 2015, with one in every fifteen children dying before their fifth birthday [4].

According to the United Nations (UN) commission on life-saving commodities for women and children, many of these deaths are due to conditions such as pneumonia, diarrhea and malaria, which could easily be prevented or treated by simple and affordable medicines administered before, during and immediately after birth [5]. For instance, of the 6.3 million under-five deaths in 2013, around 15, 11 and 7% of them were caused by pneumonia, diarrhea and malaria, respectively [6]. Yet, early diagnosis and treatment with simple antibiotics could avert as many as 600,000 of deaths in case of pneumonia whereas, improving access to ORS would save as many of 1.3 million children who are dying annually from diarrhea [3, 7].

In 2011, the WHO departments of essential medicines and health products and other stakeholders developed a list of priority life-saving medicines for women and children with the main aim of supporting countries to plummet maternal, newborn and child morbidity and mortality [8]. According to this document, priority life-saving medicines are medicines which have the potential to save lives of children that should be available in all health systems and at all times. Medicines for the management of pneumonia, diarrhea, malaria, neonatal sepsis, HIV, vitamin A deficiency, tuberculosis and pediatric palliative care have been included under priority life-saving medicines for children’s health [8, 9].

Albeit some availability and affordability surveys [10, 11] have been conducted for children and adult on essential medicines, to the best of our knowledge, there was no a single previous study carried out to assess availability and affordability of the WHO recommended pediatric priority life-saving medicines in Ethiopia. Hence, the main aim of this study was to examine the availability and affordability of the life-saving priority medicines for children under five-years old in health facilities found in Tigray Region, Northern Ethiopia.

A cross-sectional study was conducted in Tigray region, Ethiopia from December 2015 to July 2016. Tigray region lies in the Northern part of Ethiopia. It borders Eritrea to the north and Sudan to the west, while in the east it shares a regional border with the Afar region and in the south-west with Amhara region. The region is sub-divided into 7 administrative zones and 52 districts with its capital in Mekelle. The region has a population of 4,314,456, of which 630,862 are children under five years of age as per 2007 national census [12]. The health care system in the region comprises of tertiary and referral hospitals, zonal hospitals, district hospitals, health centers and health posts.

According to the findings of this study, the overall availability of priority life-saving medicines was found to be low. Due to variation in medicine pricing policy, methodology, types of prevalent disease, and medicine supply systems, it is difficult to make a comparative analysis of medicines availability. However, this result is in agreement with studies of the availability and affordability of essential medicines in Ethiopia [10] and elsewhere [18, 24, 25]. This calls for urgent action to address the availability of life-saving medications in the region.

The average availability of lowest priced medicines for children was 41.9% in the public and 31.5% in the private sectors. These findings are lower than a study done in Western part of Ethiopia [10] which reported 43% for public and 42.8% for private sectors; comparable with reports of a study conducted in Guatemala [22] which found an availability 46% in public sector and 35% in private sector whereas higher than the study done by Wang et al. 2014 [18] in China, which reported availability of 27.3% for public sector and 20.6% for private sector. In agreement with the studies done elsewhere [18, 22], the present study showed that availability of medicines was higher in the public sector than in the private sector. However, considering the particular health service needing population, still, the figure in public sector was very low. The low availability of medicines at public hospitals could have direct implications on access, as patients are then persuaded to purchase these medicines from private pharmacies where quite often are sold for higher price. Private pharmacies most of the time carry fewer generic drugs than the public sectors; as a result, they may dispense more brand medicines. Obviously, brands are more costly than their generic equivalents that lead the patients to dig deep into their pockets to pay for medicines [26].

It was noted in this study that 11 medicines out of the 27surveyed priority life-saving medicines were absent in both private and public sectors. Particular concerning is the unavailability of rectal artesunate, ampicillin (250 mg and 1 g) injection and medicinal oxygen, which are the WHO recommended life-saving priority medicines for the treatment of malaria and pneumonia, even though lower respiratory tract infections including pneumonia and malaria are the foremost causes of death and disease burden among under-five children in Ethiopia [27, 28]. This finding is in line with a study done in Uganda [29]. According to some of the administration of the medicine outlets, the possible reason for the lower availability of ampicillin formulations in this study was due to the choice of ceftriaxone injection for many conditions over ampicillin. In addition to ampicillin and artesunate, all of the morphine dosage forms for palliative care and pain management and medicinal oxygen gas for pneumonia were absent in this study. The observed lack of availability of morphine could be partly tied to pethidine, which is the first line for pain management as compared to morphine, which is listed as the alternative treatments for pain management in the country’s standard treatment guideline [19].

Despite its known clinical benefit and proven effectiveness in reducing mortality from pneumonia [30], medicinal oxygen was found to be absent in almost all sectors surveyed in this study. This finding is very disquieting because oxygen is perhaps the only drug with no alternative agent [31]. Oxygen therapy should therefore be available for children care in every sector especially for the management of pneumonia as it is the leading cause of death in children under-5 worldwide.

The prices of priority life-saving medicines in this study were relatively higher as compared to IRPs. There was a variation in prices for medicines in public and private sectors. In the public sector, they were sold at 1.5 times their IRP and 2.7 times their IRP in the private sector. Similar findings were reported in another local study [10] as well as studies in South America [22] and Asia [18]. The reason for the lower price of medicines in public sectors could be the effort made by the Ethiopian government to reduce drug prices over the last decade by designing various mix of policies to regulate the price on pharmaceutical products so that there would not be higher price mark-ups in public sectors.

Despite the fact that it is difficult to assess true affordability, treatments costing one day’s wage or less are generally considered affordable. Assessed accordingly, in the current study, about 30% of medicines in public sector and 50% of them in private sector were unaffordable. This shows that a significant segment of the population would not be able to pay for their medicines. Even medicines like amoxicillin, paracetamol tablet and gentamicin which were seemed affordable for the lowest government wage could be out-of-reach for a substantial number of people in Ethiopia because around 30% of the population in the country is living below the international poverty line (defined as an income of less than $1.9/day) [32]. These costs do not even include the costs of consultation and diagnostic tests; hence, families who need medicines for more than one child may be confronted with more costs and extra days’ wages. These findings are consistent with other studies [10, 22, 33, 34] done on the affordability of essential medicines for children.

Eventhough Ethiopia achieved millennium development goal for reducing child mortality, the findings from this study advocate that availability and affordability of priority life-saving medicines for children is still low. High medicine prices and low incomes are considered as the notable barriers to the affordability of treatments particularly in developing countries. Country or regional health authorities must therefore improve the availability of more affordable generic priority life-saving medicines in the public sector by monitoring efficiency of the public sector procurement system as well as encouraging local pharmaceutical manufacturing. Besides, regulatory authorities need to provide a regulatory and enforcement mechanism in which cheaper alternative medicines would be more often prescribed, dispensed and used than newer, more expensive medicines. In general, this study suggests the regional priority life-saving medicine policy to be established, developed and enforced at both public and private sectors to ensure availability and affordability to basic health services, particularly for the poor.

This study has a certain limitation. It did not explore the factors affecting the availability and utilization of the priority medicines for children in public and private health facilities in Tigray region. Undertaking a more in-depth study to explore the underlying factors is needed. The study did not survey medicine procurement prices at wholesales due to logistical constraints. Percentage of medicines availability at the time of data collection may not be the same all year long. Since the study was predominantly based on WHO/HAI methodology, the concerns pertaining to the representativeness of the selected medicine outlets still can arise. Moreover, patient charges in all sectors were compared with IRPs, which do not consider freight and other margins and markups. This may affect the validity of the price comparison.

This study divulges that the availability and affordability of life-saving priority medicines for children under-five were limited in health facilities of the region in spite of the WHO emphasis. This result calls for urgent action to address the availability of life-saving medications in the region. An integration of these life-saving medicines into the logistic and essential drug list of the health facilities remains pertinent to increase their availability and affordability.