2 17 ..

2556

The Prices, Availability and Affordability of Essential Medicines in Sudan

Mohammed Musa *

Abstract
This study aims to analyze the prices, availability and affordability of selected essential medicines (EM) in Sudan, and to assess factors affecting medicines prices variation between the Capital and other states. The methodology developed by the World Health Organization (WHO) and Health Action International (HAI) was used to assess the prices, availability and affordability, while Ordinary Least Square (OLS) was used to estimate factors affecting price variation. Primary data to 50 essential medicines were collected from102 medicines pharmacies (35public, 36 private, 31 Revolving Drug Fund RDF) in six states. Medicine prices were compared with international reference prices (IRPs) to obtain a median price ratio. The daily wage of lowest paid unskilled government worker (LPGW) was used to gauge the affordability of medicines. In private pharmacies, innovator brand (IB) prices were 7.1 times higher than IRPs, while generics were 4.26 times higher. In public pharmacies they were 3.93 times higher for IBs and 4.38 for generics. While for RDF was 2.77 for IBs and 4.12 for generics. The RDF sector was 67% higher than the government procurement prices, but lower by 6.6% in generic and 34.5% in IB from the private sector MPRs, and by 47.2% in IB and 8.1% in generics from the public sector. In the public sector the availability of EM was 64.1% for the generics and 3.3% for IBs. While the Availability of IB in the private sector was 14% and the generics was 83.7% and the availability of generics in the RDF sector was 50% and for IBs was only 4%. Moving from the capital to remote states the price ratio varied from 9% to 278% as estimated in this study. Key Words: Sudan/ Essential Medicine/ Medicine Prices, Availability, Affordability

Introduction
Medicines account for 20% 60% of health spending in low and middle income countries where up to 90% of populations purchase their medicines out of their pocket (Cameron, et al 2009). In Africa 50% to 60% of population cannot get access to their essential medicines (Tetteh, 2008). Either due to low availability or high level of prices made them unaffordable. Medicines not like other commodities, patients have no chance to choose alternative, for that reason access to Essential Medicines (EM) is of significant importance to achieve the minimum status of

Masters Student, Master of Science inHealth Economics Program, Chulalongkorn University; E-mail: mohyusif@yahoo.com

[48]

 2 17 ..2556
health for large possible group of people. Availability which is "the physical access" and affordability "the economical access" of EM are two key factors to EM access (Frost & Reich, 2008). Since November 2007 when the country seceded into two parts, Sudan, the remaining part lost more than 70% of its oil resources causing economic instability, inflation started to grow rapidly, in 2012 inflation reached over 40% driven by higher transportation costs and rising import costs for basic goods basically medicines prices. Medicine price mark-up in private sector in Khartoum state reached up to 94%, in other states it could be greater (Ali & Yahia, 2012). Ali and Yahia concluded that 23% of surveyed medicines were more 10 times the international reference price. Medicines surveyed in that study were most sold generics rather than essential medicines.

Objective and Scope

Objective: The general objectives of this study 1) To identify availability status of selected essential medicines in Sudan a cross public, private and RDF sectors. 2) To compare the prices of the selected essential medicines with the international reference price across Sudan states, private, public and RDF sectors. 3) To analyze affordability of selected standard treatment for common disease. 4) To analyze factors that affect medicine prices variation between state of the capital and other states. Scope Study 50 selected essential medicines in private, public and the Revolving Drug Fund (RDF) in six states in Sudan (Khartoum, Gazeera, River Nile, West Darfur, Sinnar and Red Sea) in February to March, 2013. In each state 6 private medicine outlets, 5 to 6 public medicine outlets and 5 to 6 RDF medicine outlets were randomly selected from a list of pharmacies registered by Ministry of Health

Literature Review
In May 2003, WHO in collaboration with Health Action International (HAI) published a manual, Medicines Prices a New Approach to Measurement (WHO/HAI, 2008a). The manual describes a standardized methodology for collecting price data, availability, and affordability of selected medicines (brand and generics) from outlets in public, private and other sectors in a s tate or country. The methodology allows for determining medicine prices and price components in comparison to an international reference price (IRP). The affordability in this methodology is measured in terms of the daily [49]

 2 17 ..2556
wages of the lowest paid government worker. Distribution of completed surveys of medicine prices and availability conducted according to the WHO/HAI survey methodology, by WHO regions, 20012008 showed in Table 1 below. Table 1: Surveys completed using WHO/HAI Methodology, 2001-2008. Number of participating countries WHO region Africa The Americas South- East Asia Europe Eastern Mediterranean Western Pacific 11 6 4 6 11 5 Source: (Cameron, A. et al, 2011)

Number of completed surveys 11 6 10 6 14 6

WHO/HAI standard methodology was validated for possible bias, because of the selection of pharmacies to be surveyed restricted within 3 hours travelling from big cities and purposive selection of regions, the validation found no significance difference on results if the sample expanded to include further pharmacies (Madden et al., 2010). A survey conducted in Sudan in 2009 on Essential Medicines availability, but on that survey other sectors were not considered, only public sector was surveyed (Cheraghali & Idries, 2009). Pricing policies in low and middle-income countries are less well developed, for example, few countries employed pricing policies such as external reference pricing (Espin et al., 2011). In low and middle income countries the markup medicine prices is varing cross countries (Cameron, A. et al, 2008). The extent to which price competition from generic medicines entry lead to price reductions; which depend mainly on market share of generic medicines (Dylst & Simoens, 2011) (see table 2 below) Table 2 medicine price mark-up in selected low and middle income countries Total cumulative% mark-up in Total cumulative% mark-up in Country public sector private sector El Salvador 165-6894% Ethiopia 79-83% 76-148% India 29 -694% Malaysia 19-46% 65-149% Mali 77-84% 87-118% Magnolia 32% 68-98% Morocco 53-93% Uganda 30-66% 100-358% [50]

 2 17 ..2556
Pakistan 28 35%

Pitfalls in international comparisons when taking Median Price Ratio (MPR) in two or more countries to compare the interpretation of the result, can be rather difficult as the medicines market volumes may differ, the surveys themselves might be conducted in different years with countries subjected to divers inflation rate and having different retail buying power of the local currency, adjustment the data for inflation and purchasing power parity (PPP) is necessary (WHO/HAI, 2008b). Two approaches are generally used to estimate affordability. One relies on the ratio of expenditures to household resources, while the second approach focuses on the residual income after expenditure (LM Nins et al., 2012). However WHO/HAI standardized methodology use days wage of lowest paid government worker to gauge affordability. Generics promotion can increase prices gap between generics and innovator medicines, in Brazil the price difference between generic and innovator medicines increased in the subsequent four-year period after generic launching by 68%(Vieira & Zucchi, 2006).

Research Methods
Study design
This study is a descriptive cross sectional study aims to analyze the prices, availability and affordability of selected essential medicines in Sudan in 6 states, comparing public, private and RDF sectors with international reference prices, using primary and secondary data.

Survey Model
WHO and HAI Medicine Price Methodology

Survey setting
Six states in Sudan (including state of the Capital)

Survey sample
Representative sample of 36 private, 35 public and 31 RDF pharmacies (n = 102) Survey sector: Public pharmacies, Private Pharmacies, RDF Pharmacies Survey areas (sample unit): states 6 States. Sampling technique: Multistage clustered sampling technique Stage 1: State selection State of the capital selected purposively; because it is centre of Sudan, higher population more than 7 million and base for all pharmaceutical companies, local manufacturer and National Medicines Regulatory Authorities. The country then stratified in to 5 regions, North, South, East, West and conflict area, from each one state randomly selected. (Red Sea, River Nile, Sinnar, Gazeera and West Darfur) Stage 2: Medicine outlets selection [51]

 2 17 ..2556
In each selected state in stage 1, Public medicine outlets selection: the pharmacy of outpatient care unit in regional public hospital purposively selected, because it represent the basic and standard public sector services, expected to have all essential medicines, the rest of the 5 medicine outlets were randomly selected from created list of public pharmacies within 3 hours traveling. RDF and Private sector medicine outlets selection: for each selected public medicine outlet, 1 private and 1 RDF medicine outlets were randomly selected from predefined list of RDF and private medicine outlets created at beginning. Stage 3: Medicines selection The 50 medicines surveyed: Global core list of 14 medicines specified by WHO, representative the global burden disease and common worldwide. Regional core list of 16, specified by WHO for EMRO region countries, they reflect and represent common disease treatment in the region. (HAI, 2008) Supplementary list, 20 medicines selected according to Sudan health priority Survey period: February - March 2013 Data collection: Primary data on availability, medicines retail prices of International Brand (IB) & Lowest Price Generic (LPG), medicines origin (imported or locally produced), government procurement prices, location of the pharmacies, and sector type. While secondary data for International Reference Prices (IRP) collected from International Medicines Price Indicators Guideline available at Management Science for Health (MSH) website. While Government Procurement Price collected from two government agencies, National health Insurance Fund (NHIF), national tender report 2013 and Health Insurance Corporation Khartoum State (HIKS) direct negotiation prices

Calculate the Median Price Ratio (MPR)

MPR if it is one means that local price equal to international price, and if it is two then; local price is double interracial price. Compare MPRs for all medicines cross private, public and RDF sectors, then the differences between government procurement prices and retail prices of public, private and RDF sectors.

Availability calculation method

Availability is defined as the percentage of pharmacies where medicines were available at survey time.

[52]

 2 17 ..2556
The availability of individual medicine (IB, LPG) cross all cross were calculated and compared to see differences between private, public and RDF sectors Affordability calculation method The MP obtained used as unit price to calculate standard treatment cost; for acute conditions full treatment cost for whole course was calculated, while 1 month treatment for chronic disease was considered. Treatment costs obtained were compared to day wage of lowest paid unskilled government worker (12.17 SDG = US$ 2.75) Table 3 below show the 14 common conditions assessed for availability. Table 3: List Standard treatment for common conditions Condition Medicine Strength 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Asthma Diabetes Hypertension Hypertension Hypercholesteromia Depression Adult RTI Pediatric RTI Adult RTI Adult RTI Anxiety Arthritis Pain/inflation pediatric Peptic ulcer Salbutamol Glibenclamide Atenolol Captopril Simvastatin Amitriptyline Ciprofloxacin

1inhalor of 200 doses 1cap/tab2/day30days = 60 1cap/tab30days = 30 1cap/tab2/day30days = 60 1cap/tab30days = 30 1cap/tab3/day30days = 90 1cap/tab2/day for 7days = 14 Co-trimoxazole 8+40mg/ml suspension 5ml2/days7days = 70ml Amoxicillin 500mg cap/tab 1cap/tab3/day 7days = 21 Ceftriaxone 1g/vial injection 1 injection Diazepam 5mg cap/tab 1cap/tab7day =7 Diclofenac 50mg cap/tab 1cap/tab2/day30days = 60 Paracetamol 24mg/ml suspension 120mg(=5ml)3/day3days=45 Omeprazole 20mg cap/tab 1cap/tab30days = 30

Dosage Form 0.1mg/dose inhaler 5mg cap/tab 50mg cap/tab 25mg cap/tab 20mg cap/tab 25mg cap/tab 500mg cap/tab

Treatment schedule

Factors affecting medicine price ratios variation: Ordinary Least Square (OLS) was used to estimate coefficients of factors affecting medicines price ratio variation between the capital and other states, the linear model used was

Where: (Pstate/Pcaptal)i: is the medicine price ratio between capital and other states

[53]

 2 17 ..2556
0 : Constant term 1 - 10 : Are the coefficients of the explanatory variables. siti : is dummy variable =1 if the site of the pharmacy is urban site, = 0 if rural site Sec1i : is dummy variable =1 if the sector is private; otherwise = 0 Sec2i : is dummy variable = 1 if the sector is RDF; otherwise = 0 souri: is dummy variable = 1 if the medicine is imported, = 0 if locally produced typi: is dummy variable = 1 if the medicine is generic, = 0 if it is brand disti : Distance of the state from the capital in km state1i: is dummy variable = 1 if the state is West Darfur; otherwise = 0 state2i: is dummy variable = 1 if the state is Gazeera; otherwise = 0 state3i: is dummy variable = 1 if the state is Sinnar; otherwise = 0 state4i: is dummy variable = 1 if the state is Red Sea; otherwise = 0 state5i: is dummy variable = 1 if the state is River Nile; otherwise = 0 i : error term The dependent variable: price ratio between the capital and other states used to estimate factors affecting variations in prices between them, state used as dummy to catch all variables driven by state (mark-up, pricing policies, degree of competition, etc..)

Results
Medicine prices:
RDF sector it has the lowest MPR in IB (2.77) and LPG (3.97) compare to the 2 other sectors. But the private sector has low MPR for LPG (4.26) when compared to public (4.38) and the highest MPR for IB (6.23); see table 4 below. Table 4 MPRs for IB and LPG in all sectors GPP Brand Generic 2.70

Public 3.93 4.38

Private 6.23 4.26

RDF 2.77 3.97

The MPR of public sector is 62.4% higher than Government Procurement Price (GPM) for LPG comparing 45 items as showed in Table 5 below. Table 5 Comparison between GPP and public sector Procurement Public Sector [54]

# of Meds. in Both

% difference Public to

 2 17 ..2556
(n=2 orders) Lowest Price 2.57 (n=35 outlets) 4.17 Sectors 45 Procurement 62.4%

Private sector was higher than GPP by 53.5% comparing 49 LPGs [see table 6] Table 6 Comparison between GPP and private sector Procurement Private Sector (n= 2) (n=36 outlets) Lowest Price 2.7 4.15

# of Meds. in Both Sectors 49

% difference Private to Procurement 53.5%

RDF was higher by 41.9% than GPP when comparing 42 LPG [see table 7] Table 7 Comparison between GPP and RDF sector Procurement RDF Sector (n=2 orders) (n=28 outlets) Lowest Price 2.7 3.83

# Of Meds. in Both Sectors 42

% difference RDF to Procurement 41.9%

Table 8 MPRs diferences between RDF and Private sector Private Sector RDF Sector (n=28 # of Meds. in Both % difference RDF (n=36 outlets) outlets) Sectors to Private Brand 4.23 2.77 6 -34.5% Lowest Price 4.41 3.97 46 -9.9% The MPR of IB in RDF sector when compared to the private sector, found to be lower by 34.5% (comparing 6 IBs), while the MPR for LPG is less by 9.9% (comparing 46 LPGs). According to results showed in Table 8. In Table 9 below public sector found to be higher by 47.2% in MPR for IBs and 11.3% for LPG when compared to RDF sector. Table 9 MPRs differences between RDF and public sectors Public Sector RDF Sector # of Meds. in Both (n=35 outlets) (n=28 outlets) Sectors Brand 2.47 1.30 2 Lowest Price 4.48 3.97 46

% difference RDF to Public -47.2% -11.3%

[55]

 2 17 ..2556
In the findings below in table 10 the public sector is higher than private sector in MPR of LPG by 5.3% and 20% for IB. Table 10 MPRs differences between RDF and public sectors Public Sector Private Sector # Of Meds. in Both (n=35 outlets) (n=36 outlets) Sectors Brand 3.93 3.14 3 Lowest Price 4.38 4.15 49

% difference Private to Public -20.0% -5.3%

Availability
The availability of medicines varies between sectors across medicines [see table 5] and the Private sector has better availability of LPGs and IB [see tables 5 & 6], although the availability of IBs was generally very low. [See tables 11 & 12] Table 11: The Availability of IBs and LPGs by sectors degree of availability Greater than 80% From 50% to 80% From 30% to 49% Less than 30% Not available Total items surveyed Lowest Price Generic Public 16 17 13 3 1 50 Private 39 7 1 2 1 50 RDF 13 17 9 8 3 50 Public 0 0 2 1 41 44 Brand Private 0 4 4 6 30 44 RDF 0 1 0 5 38 44

Table 12: Items with Availability greater Than 95% in private and it is correspondence in other sectors Brand Private (n=36) 8.3% 5.6% 50.0% 8.3% 0.0% Lowest Price Private (n=36) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Medicine Name Diclofenac 25mg Amlodipine 5 g tab Paracetamol 500mg tabs Omeprazole 20mg tab Ciprofloxacin 500 mg Adult cough preparation

Public (n=35) 0.0% 0.0% 5.7% 0.0% 0.0%

RDF (n=31) 0.0% 0.0% 6.5% 0.0% 0.0%

Public (n=35) 97.1% 94.3% 94.3% 91.4% 88.6% 82.9%

RDF (n=31) 83.9% 74.2% 83.9% 71.0% 77.4% 77.4%

[56]

 2 17 ..2556
expecto. Ferrous Sulphate + Folic acid Amoxicillin + Clavulanic Acid 1g Amoxicillin Cefixime Ceftriaxone injection Hyoscine -N-Butylbromide Ranitidine Carbamazepine Artemether injection 82.9% 40.0% 82.9% 80.0% 77.1% 77.1% 77.1% 77.1% 68.6% 100.0% 100.0% 97.2% 97.2% 97.2% 97.2% 97.2% 97.2% 97.2% 74.2% 74.2% 64.5% 67.7% 74.2% 71.0% 74.2% 51.6% 58.1%

2.9% 0.0% 5.7% 0.0% 0.0% 0.0% 5.7%

16.7% 0.0% 36.1% 0.0% 2.8% 8.3% 63.9%

0.0% 0.0% 12.9% 0.0% 0.0% 0.0% 9.7%

Out of 50 IBs three medicines were not assessed for their IB, as they havent got IBs; these medicines were Adult cough syrup, Ferrous sulphate + folic acid, Artesunate 50mg and 100mg and Oral rehydration salt. Table 13: Availability of the other medicines surveyed Brand Medicine Name Public Private (n=35) (n=36) Glibenclamide 5 mg tab 0.0% 2.8% Atenolol 50 mg tab 0.0% 27.8% Co-trimoxazole suspension 0.0% 0.0% Metronidazole 20 mg tab 0.0% 5.6% Amoxicillin + Clavulanic Acid 375mg 0.0% 5.6% Lisinopril 10mg tabs 0.0% 33.3% Artesunate 50mg tab Diclofenac 50 mg tab 0.0% 8.3% Amoxicillin suspension 250mg 0.0% 0.0% Nifedipine Retard 20mg 0.0% 2.8% Furosemide 40mg tab 2.9% 5.6% Metformin HCL 500mg 2.9% 25.0% Azithromycin suspension 0.0% 8.3% Salbutamol syrup 2.9% 47.2% Ibuprofen 400mg tab 0.0% 2.8% Metronidazole 500 mg 0.0% 2.8% Carbimazole 5mg tab 37.1% 19.4% Atorvastatin 20mg tab 0.0% 0.0% [57]

RDF (n=31) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 12.9% 3.2% 16.1% 0.0% 0.0% 9.7% 0.0%

Public (n=35) 97.1% 88.6% 88.6% 80.0% 68.6% 68.6% 48.6% 45.7% 85.7% 82.9% 82.9% 82.9% 77.1% 77.1% 71.4% 54.3% 14.3% 62.9%

Lowest Price Private (n=36) 94.4% 94.4% 94.4% 94.4% 94.4% 94.4% 94.4% 94.4% 91.7% 91.7% 91.7% 91.7% 91.7% 91.7% 91.7% 88.9% 88.9% 86.1%

RDF (n=31) 77.4% 74.2% 71.0% 71.0% 58.1% 61.3% 35.5% 32.3% 71.0% 35.5% 71.0% 38.7% 74.2% 51.6% 74.2% 45.2% 29.0% 32.3%

 2 17 ..2556
Artesunate 100mg tab Norethiesterone 5mg tab Paracetamol suspension Chloramphenicol eye drops Diazepam 5mg tab Oral rehydration Salt Dexamethasone injection Salbutamol inhaler Amitriptyline 25mg tab Gliclazide 80mg tab Albendazole 200mg Beclomethasone inhaler Simvastatin 20 mg Captopril 25 mg Artemether+ Lumefantrine Insulin, Neutral Soluble Fluoxetine 0.0% 0.0% 0.0% 0.0% 0.0% 28.6% 0.0% 0.0% 2.9% 0.0% 0.0% 0.0% 5.7% 42.9% 0.0% 36.1% 2.8% 0.0% 0.0% 66.7% 0.0% 13.9% 5.6% 8.3% 0.0% 0.0% 61.1% 25.0% 2.8% 9.7% 0.0% 0.0% 0.0% 0.0% 58.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 19.4% 19.4% 0.0% 40.0% 37.1% 85.7% 71.4% 51.4% 37.1% 45.7% 62.9% 48.6% 40.0% 34.3% 48.6% 31.4% 42.9% 20.0% 14.3% 2.9% 86.1% 86.1% 83.3% 83.3% 80.6% 80.6% 75.0% 72.2% 72.2% 69.4% 63.9% 58.3% 50.0% 47.2% 16.7% 16.7% 13.9% 32.3% 25.8% 61.3% 38.7% 45.2% 45.2% 41.9% 0.0% 22.6% 22.6% 12.9% 22.6% 19.4% 22.6% 0.0% 6.5% 0.0%

Table14: Mean Availability of EM in Different Sectors Public Sector (n=35 ) Brand Lowest Price 3.31% 64.06%

Private Sector (n=36 )

RDF Sector (n=31) 4.04% 50.00%

Mean Percent Availability 14.84% 83.67%

The availability of EM of LPGs in the private sector is high (83.67%), but in RDF this was found to be very low (50%). Then RDF objectives will be in question regarding access in terms of availability. Public sector availability was found to be fair (64.06%), 83% of surveyed public facilities operated by National Health Insurance Fund (NHIF) who refund to their subscribers the bills of unavailable medicines. (See table 7)

Affordability
Diazepam 5mg, Paracetamol suspension, Co-trimoxazole suspension, Atenolol 50mg and Artesunate 100mg all of them were found to cost less than 1 days wage of the lowest unskilled government worker in all sectors. The cost of treatment of diabetes by Glibenclamide 5mg cost more than 1 days wage in private and RDF, but less in the public sector. [See figure2]. However as shown in table 15, the public sector was slightly less affordable when compared to the two other sectors. Only in six conditions were found to cost less than one days wage in all sectors. [58]

 2 17 ..2556
Figure 1: Day wage for LPGW required getting standard treatment

Table 15 Affordability: Number of days' wage of LPGW needed for standard treatment Disease Adult respiratory infection Arthritis Adult respiratory infection Hypertension Asthma Malaria for Adult Peptic Ulcer Depression Hypercholesterolemia Asthma Adult respiratory infection Adult respiratory infection Diabetes Adult Malaria Tonsillitis in Children Hypertension Pediatric RTI Pain/inflammation Medicine Amoxicillin + Clavulanic Diclofenac Ceftriaxone injection captopril Salbutamol inhaler Artemether injection Omeprazole Amitriptyline Simvastatin Salbutamol inhaler Ciprofloxacin Amoxicillin Glibenclamide Artesunate Azithromycin suspension Atenolol Co-trimoxazole suspen. Paracetamol suspen. [59] Strength 1g 50mg 1 g/vial 25mg 100 mcg/d 80mg/ml 20 mg 25mg 20mg 50 mcg/d 500 mg 500 mg 5 mg 100 mg 40mg/ml 50 mg 8+40mg/ml 25mg/ml IB/LPG Generic Generic Generic Generic Brand Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Days Wage Public Private 5.8 5.1 5.3 4.9 4.6 1.2 3.2 1.6 3.1 2.5 2.8 3.0 2.6 2.5 2.2 2.2 2.1 2.0 1.6 1.4 1.2 1.2 1.1 1.1 0.5 1.5 0.9 0.9 0.8 1.2 0.7 0.5 0.4 0.5 0.2 0.3 RDF 5.1 4.7 1.0 1.0 1.3 2.5 2.3 1.5 1.4 0.0 1.0 1.0 1.5 0.8 0.6 0.5 0.4 0.3

 2 17 ..2556
Anxiety Adult respiratory infection Hypertension Diazepam Amoxicillin + Clavulanic Atenolol 5 mg 1g 50 mg Generic Brand Brand 0.1 0.0 0.0 0.1 9.1 5.2 0.1 0.0 0.0

Factors affect medicines price ratios between capital and other states: Table 16 below shows the factor that have significance role to change the price ratios Variables Constant State1 State2 State3 State4 State5 Sector2 Sector1 Distance type Site sour Coefficient 1.0117 2.7789 0.3128 0.5537 1.5481 0.0930 0.0443 0.1138 0.0023 -0.1647 0.0685 0.0681 Std. Error 0.1609 1.2682 0.1772 0.2731 0.7134 0.0270 0.0646 0.0616 0.0009 0.1150 0.0844 0.0694 t-ratio 6.2868 2.1912 1.7651 2.0272 2.1699 3.4392 0.6853 1.8475 2.5354 -1.4319 0.8116 0.9821 p-value <0.00001*** 0.0285 ** 0.0776 * 0.0427 ** 0.0301 ** 0.0006 *** 0.4932 0.0648 * 0.0113 ** 0.1523 0.4171 0.3261

States variations have their characteristic effect on medicine price ratios, the same as distance. Moving from Khartoum, the Capital of Sudan to other states has an extra charge on price of medicines patients have to pay

Conclusion
Generally the availability of IBs found to be very low, in the public sector was 3.31%, 14.84% in the private sector and 4.04% on RDF sector, while for LPG was 64.06%, 83.67%, 50% respectively, the private sector had better and higher availability. Medicines price in Sudan is high compared to IRP; the public sector has higher mark-up compared to the private and RDF sectors, while lowest MPR found in RDF sector. Essential Medicines unaffordable when compared to day wage of LPGW, only 6 EMs found to be affordable in the private, public and RDF sector. However Diclofenac 50mg and Amoxicillin + Clavulonic acid 1g unaffordable even for NHIF prescribers who pay 25% of medicines cost as co-payment. Revising pricing policy for medicines, exemption EM from government fees and improve public sector EMs availability are key recommendations to improve access to EM in Sudan. [60]

 2 17 ..2556

References
Cameron, A., Ewen, M., Ross, D. L., Ball, D., & Laing, R. 2009. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. The Lancet 373(9664) : 240 - 249. doi: 10.1016/S0140-6736(08)61762-6 Ali, G. K., & Yahia, Y. 2012. Controlling medicine prices in Sudan: the challenge of the recently established medicines regulatory authority. East Mediterrian Health18(8) : 811-820. Anson, A., Ramay, B., de Esparza, A. R., & Bero, L. 2012. Availability, prices and affordability of the World Health Organization's essential medicines for children in Guatemala. Global Health 8 (22). doi: 10.1186/1744-8603-8-22 Babar, Z. D., & Izham, M. I. 2009. Effect of privatization of the drug distribution system on drug prices in Malaysia. Public Health 123(8) : 1-2. doi: 10.1016/j.puhe.2009.06.011 Babar, Z. U., Izham, M. I., Singh, H., Bukahri, N. I., & Creese, A. 2007. Evaluating drug prices, availability, affordability, and price components: implications for access to drugs in Malaysia. PLoS Med 4(3) : 2. doi: 10.1371/journal.pmed.0040082 Babar, Zaheer Ud Din, Ibrahim, Mohamed Izham Mohamed, Singh, Harpal, Bukahri, Nadeem Irfan, & Creese,A. 2007. Evaluating Drug Prices, Availability, Affordability, and Price Components: Implications for Access to Drugs in Malaysia. PLoS Med 4(3), e82. doi: 10.1371/journal.pmed.0040082 Ball, Douglas. 2011. The Regulation of Mark-ups in the Pharmaceutical Supply Chain. http://www.haiweb.org/medicineprices/05062011/Mark-ups%20final%20May2011.pdf. Bate, R., Jin, G. Z., & Mathur, A. 2011. Does price reveal poor-quality drugs? Evidence from 17 countries. Journal of Health Economics 30(6) : 1. doi: 10.1016/j.jhealeco.2011.08.006 Bertoldi, Andra Dmaso, Helfer, Ana Paula, Camargo, Aline L, L, Nomia U, Tavares, & Kanavos, Panos. 2010. Medicine prices, availability and affordability in Southern Brazil: a study of public and private facilities The London School of Economics and Political Science. Retrieved from http://www2.lse.ac.uk/LSEHealthAndSocialCare/pdf/LSEHealthworkingpaperseries/LSEHWP18.pdf (Working Paper No. 18/2010) Cameron, A., Ewen, M., Auton, Martin, & Dele , A. 2011. The World Medicines Situation 2011: Medicines Prices, Availability and Affordability. Retrieved from http://www.who.int/nha/docs/world_medicine_situation.pdf Cameron, A., Ewen, M., Ross-Degnan, D, Ball, D, & Laing, R. 2009. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis (vol 373, pg 240, 2009). Lancet 373(9664) : 632-632. Cameron, A., Roubos, I, Ewen, A. , Teeuwisse, H. , Leufkens, & Laing, R. 2011. Differences in the availability of medicines for chronic and acute conditions in the public and private sectors of developing [61]

 2 17 ..2556
countries. Bulletin of the World Health Organization 89(6) : 412-421. Espin, J., Rovira, J., & Labry, A. 2011. Pharmaceutical Pricing Policies and Interventions, External Reference Pricing. from http://www.haiweb.org/medicineprices/24072012/ERPfinalMay2011.pdf. Cameron, A, Roubos, I, Ewen, M., A, Teeuwisse., Leufkens, H., & Laing, R. 2011. Differences in the availability of medicines for chronic and acute conditions in the public and private sectors of developing countries. Bulletin of the World Health Organization 89 : 412-421. doi: 10.2471/BLT.10.084327. Gelders, S., Ewen, M., Noguchi, N., & Laing, R. 2005. Price, availability and affordability An international comparison of chronicdisease medicines. doi:WHO-EM/EDB/068/E/05.06/3000. Kotwani, A., Ewen, M., & Laing, R. 2006. A standardized methodology to measure medicine prices, availability, affordability and price components in developing and transitional countries. The International Journal of Tuberculosis and Lung Disease 9(3) : A57-A58. doi: Doi 10.1016/S10983015(10)64482-8. Kotwani, A., Ewen, M., & Laing, R. 2006. A standardized methodology to measure medicine prices, availability, affordability and price components in developing and transitional countries. Value in Health 9(3) : A57-A58. doi: Doi 10.1016/S1098-3015(10)64482-8. LM Nins, a, E Van de Poel, a, A Cameron, b, M Ewen, c, Laingb, R, & Brouwera, & WBF. 2012. Practical measurement of affordability: an application to medicines. Bull World Health Organization 90(3) : 219227. Meiners, C., Sagaon-Teyssier, L., Hasenclever, L., & Moatti, J. P. 2011. Modeling HIV/AIDS drug price determinants in Brazil: is generic competition a myth? PLoS One 6(8), e23478. doi: 10.1371/journal.pone.0023478. Simoens, S. 2007. International comparison of generic medicine prices. Curr Med Res Opin 23(11) : 26472654. doi: 10.1185/030079907x233395. WHO/HAI. 2008. Measuering Medicine prices, availability, affordability and price components. 293. Health Action International. (2008). Global and Regional Core Medicines. From http://www.haiweb.org/medicineprices/manual/medpricesAttachements/surveyDocs/GlobalRegC oreMedsDec08.doc.

[62]