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Comparative Analysis of Prescription Drug Prices in South Asian Association for Regional Cooperation Countries
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Contents lists available at sciencedirect.com Journal homepage: www.elsevier.com/locate/vhri
Comparative Analysis of Prescription Drug Prices in South Asian Association for Regional Cooperation Countries Dileep K. Rohra, MBBS, PhD,1,* Omar A. Abuomar, MBBS,1 Peter M.B. Cahusac, PhD,1,2 Angela Dangol, MBBS,3 Priyanga Ranasinghe, MBBS4 1 Department of Pharmacology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; 2Department of Comparative Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; 3Nepal Medical College, Kathmandu University, Jorpati, Kathmandu, Nepal; 4Department of Pharmacology, University of Colombo, Colombo, Sri Lanka
A B S T R A C T Objectives: The SAARC (South Asian Association for Regional Cooperation) is a geopolitical organization composed of 8 neighboring countries: Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka. The objective of this study was to compare the prices of some selected drugs in SAARC countries. Methods: A list of 24 drugs was prepared based on certain inclusion and exclusion criteria. The retail prices of the drugs were determined from different sources and verified manually in the open market. The prices obtained in local currencies were converted into US dollars for comparison purposes. In another analysis, the gross domestic product (GDP) of each country was factored for comparative analysis. Results: Out of the 23 drugs, 17 comparisons across countries were statistically different at P , .05. These analyses revealed large differences in drug prices among SAARC countries. The GDP-adjusted median drug prices revealed a more polarized picture, with Nepal generally having the highest prices (19 out of 24 drugs) and Sri Lanka having the lowest (19 out of 24 drugs). For example, the widely used antipsychotic drug risperidone was 7 times more expensive in Pakistan ($0.316) compared with Sri Lanka ($0.045). Adjusting for GDP made risperidone more than 18 times more expensive ($21.90 and $1.20) across the same 2 countries. Conclusion: Prices of selected drugs varied markedly in SAARC countries. After adjusting for GDP, drug prices became more polarized across countries, with Nepal featuring the highest prices. In determining drug prices, the country’s GDP and the population’s purchasing power need to be taken into account. Keywords: SAARC, South Asia, drug price. VALUE IN HEALTH REGIONAL ISSUES. 2020; 21(C):113–119
Introduction The right to health is a fundamental human right, which includes access to medicine.1 A crucial factor that determines the accessibility and affordability of a medication is its price. According to the World Health Organization (WHO), policy makers should apply schemes to manage medicine prices, ensuring that citizens can easily access necessary medications.2 Medications are considered a public health product and therefore, in several countries, are funded completely or partially by the government.3 The prices of drugs are set by the pharmaceutical companies, which are regulated by the government authorities and national industry policies.4 Owing to differences in governmental policies
and pharmaceutical industry approaches, the prices of medications differ from country to country.5 Prices can also vary between countries owing to differences in the manufacturer prices or the pharmacy retail prices.4 Some medications might be relatively inexpensive but, with taxation, the consequent price for the end user becomes inordinately expensive. Cross-national price comparisons is a method used by various pharmaceutical companies and governments to set an average price level for different medications. This involves a comparison being done among diverse product samples.6 Research conducted recently to determine the differences of certain medicine prices in 16 different European countries and New Zealand showed that there was great variation.7 The differences were thought to be
Conflict of interest: The authors have indicated that they have no conflicts of interest with regard to the content of this article. * Address correspondence to: Dileep Kumar Rohra, MBBS, PhD, Department of Pharmacology, College of Medicine, Alfaisal University, P.O Box 50927, Riyadh 11533, Saudi Arabia. Email: [email protected] 2212-1099/$36.00 - see front matter ª 2019 ISPOR–The professional society for health economics and outcomes research. Published by Elsevier Inc. https://doi.org/10.1016/j.vhri.2019.09.004
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attributed to national pricing, reimbursement policies, and the economic situation of each country.7 The SAARC (South Asian Association for Regional Cooperation) is a geopolitical organization composed of 8 countries: Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka. Almost a quarter of the world population lives in these 8 countries.8 In the published literature, there are several studies that have compared drug prices across countries. Europe and North America feature strongly in these studies.9-15 To date, no study has looked at a comparative analysis of drug prices in the SAARC region. Therefore this study was conducted with the aim of comparing the prices of selected drugs in SAARC countries.
Methods Selection of Countries The SAARC consists of 8 countries. Out of these, 3 countries (Afghanistan, Bhutan, and the Maldives) do not have their own established pharmaceutical industry. Instead, they heavily rely on the supply of drugs from neighboring countries like India and Pakistan. We could not find any online database on the drug pricing in those countries; we also could not find a collaborator to help us in data collection in those countries. Therefore, those 3 countries were excluded from the study and the data of drug prices were collected from the remaining 5 countries.
Table 1. List of selected drugs analyzed for price. Drug name (INN)
Determination of Drug Prices With the objective of collecting accurate and comprehensive data on drug prices, different strategies were used for each country: 1. Bangladesh: A digital database, BDDrugs, is dedicated to providing detailed pharmaceutical information such as properties, brand and generic name, dosage form, manufacturer, and the price of the product.16 The prices of a few randomly selected products were confirmed from the open market in Dhaka to check the accuracy of the website. This exercise confirmed the reliability of the data obtained from the website. 2. India: There are various online resources, which provide the pricing information of drugs available in India. We wanted to use a database that was comprehensive and reliable. For this purpose, the source that retrieved the greatest number of brands available in India was selected.17 This showed that the database was comprehensive and retrieved most or all of the registered drugs. For the purpose of reliability and accuracy, the prices of some randomly selected drugs were checked in the open market of Ahmedabad, India, which matched those mentioned on the online source.
Selected presentation
1. Alprazolam
Benzodiazepine
0.5 mg oral
2. Amikacin
Aminoglycoside antibiotic
500 mg Injection
3. Amiodarone
Anti-arrhythmic
200 mg oral
4. Amlodipine
Ca21 channel blocker
10 mg oral
5. Amoxicillin
Penicillin antibiotic
500 mg Cap
6. Atorvastatin
HMG-CoA reductase inhibitor
20 mg oral
7. Baclofen
Skeletal muscle relaxant 10 mg oral
8. Carbamazepine
Anti-epileptic
9. Carbimazole
Antithyroid
5 mg oral
10. Carvedilol
Beta blocker
25 mg oral
11. Clarithromycin
Macrolide antibiotic
500 mg oral
12. Clomiphene
Estrogen receptor antagonist
50 mg oral
13. Clopidogrel
Antiplatelet
75 mg oral
14. Deferoxamine
Iron chelating agent
500 mg injection
15. Donepezil
Acetylcholine esterase inhibitor
5 mg oral
16. Fexofenadine
Second generation H1-receptor antagonist
180 mg oral
17. Fluconazole
Azole antifungal
150 mg oral
18. Frusemide
Loop diuretic
20 mg injection
19. Ipratropium
Antimuscarinic
40 ug/dose aerosol
20. Latanoprost
PG F2a analog
50 ug/mL eye drops
21. Levofloxacin
Fluoroquinolone antibiotic
500 mg infusion
Selection of Drugs The selection of the drugs was purely subjective; however, there were some guiding principles that were applied when finalizing the list of drugs for analysis. The list had to contain a mix of drugs from diverse pharmacological classes and with diverse clinical uses. They had to be generally widely used, come from a range of prices (from high to low), and represent multiple routes of administration. Based on these criteria, a list of 32 medications was generated. The final inclusion criterion, however, was the availability of the same drug in the open market, in exactly the same strength and presentation (pack size) in all 5 countries. This step excluded 8 drugs, leaving a final list of 24 medications (Table 1). The data of drug prices were collected for the brands available regardless of the innovator company or the generics.
Pharmacological class
22. Methylprednisolone Glucocorticoid
200 mg oral
40 mg/mL injection
23. Risperidone
Antipsychotic
4 mg oral
24. Valsartan
AT-II receptor blocker
80 mg oral
INN indicates International nonproprietary name.
3. Nepal: Because there is no online resource for retrieving the data on drugs, officials of the Department of Drug Administration in Nepal were personally approached. Data on the prices of available brands of the selected drugs were obtained from them. 4. Pakistan: For Pakistan, PharmaGuide was consulted, which is the most widely used resource for a quick reference on all the medicine available in Pakistan.18 The print version of the manual is published annually. 5. Sri Lanka: Brands available for a particular drug were identified by searching the Sri Lanka National Medicines Regulatory Authority (NMRA) website, which hosts an online database19 containing the relevant information, including the brand name and manufacturer. The prices of some drugs were checked in the open market of Colombo, Sri Lanka and double-verified. All the data were collected from November 2017 to March 2018.
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Table 2. Median drug prices in US dollars for each drug. Drug name
Kruskal-Wallis P value
Median prices in US dollars Bangladesh
India
Nepal
Pakistan
Sri Lanka
Alprazolam
0.024
0.024
0.022
0.039
0.064
< .001
Amikacin
0.559
0.927
0.381
1.130
1.525
< .001
Amiodarone
0.120
0.147
0.137
0.278
0.354
0.022
Amlodipine
0.072
0.053
0.037
0.068
0.033
< .001
Amoxicillin
0.072
0.101
0.086
0.067
0.048
< .001
Atorvastatin
0.180
0.170
0.125
0.208
0.059
< .001
Baclofen
0.096
0.112
0.149
0.038
0.151
0.006
Carbamazepine
0.042
0.025
0.024
0.030
0.044
0.002
Carbimazole
0.036
0.028
0.020
0.009
0.010
0.307
Carvedilol
0.096
0.086
0.157
0.137
0.076
0.002
Clarithromycin
0.481
0.660
0.454
0.402
0.457
< .001
Clomiphene
0.081
0.086
0.108
0.195
0.267
< .001
Clopidogrel
0.120
0.082
0.079
0.127
0.094
< .001
Deferoxamine
2.633
2.373
2.730
1.960
3.176
–
Donepezil
0.120
0.132
0.118
0.122
0.269
0.002
Fexofenadine
0.102
0.126
0.118
0.136
0.101
0.003
Fluconazole
0.241
0.283
0.236
1.247
0.254
< .001
Furosemide
0.040
0.044
0.047
0.030
0.077
0.246
Ipratropium Bromide
2.406
1.978
2.231
1.966
4.065
0.092
Latanoprost
9.461
5.224
7.719
3.764
4.034
0.183
Levofloxacin
1.203
1.772
2.007
2.147
2.629
< .001
Methylprednisolone
1.297
1.518
1.823
1.785
0.857
0.498
Risperidone
0.066
0.057
0.094
0.316
0.045
< .001
Valsartan
0.114
0.183
0.188
0.136
0.430
0.072
Note. The lowest prices for each drug are highlighted in yellow, and the highest are highlighted in blue. The final column gives P values for one-way Kruskal-Wallis analyses. Those P values highlighted in pink are P < .05.
Data Analysis All the data on prices from the SAARC countries were obtained in their local currencies. For each country, their currency value in US dollars was averaged across daily exchange rates over the month of January 2018, using the website.20 Rates obtained were as follows (giving local currencies for $1.00): 83.14 Bangladeshi Takas; 63.63 Indian Rupees; 101.83 Nepalese Rupees; 110.64 Pakistan Rupees; 153.76 Sri Lanka Rupees. This allowed all prices to be converted to US dollars. Because prices may depend on the level of gross domestic product (GDP) per capita for each country, this was factored in to some of the calculations. Country GDP per capita data were accessed from the database of the World Bank.21 All drug prices were then converted to GDP-adjusted prices using the following formula: GDP adjusted price ¼ 100 000 3 Cost US$=GDP per capita (The 100 000 constant multiplier was included to reduce the number of decimal places needed to express the values, giving a range of 0.271 to 1167.738). Preliminary parametric analyses revealed widespread heterogeneity of variances in ANOVAs, justifying the use of nonparametric analyses and the calculation of median values for more robust statistics. The following nonparametric analyses were used: Kruskal-Wallis, Friedman repeated measures, and Wilcoxon
signed ranks test. Data were entered into Excel sheets and analyzed using SPSS (IBM Corp, version 21).
Results Median drug prices in US dollars for each country are given in Table 2. Highest and lowest median prices per drug are highlighted. The last column of Table 2 gives the P values obtained from Kruskal-Wallis ANOVAs for each of the 23 drugs (deferoxamine was excluded because it had only 1 brand in each of the countries). Out of the 23 drugs, 17 comparisons across countries were statistically different at P , .05 (many were P , .001). These analyses revealed large differences in drug prices among SAARC countries. For example, 12 of the drugs with the highest median prices were in Sri Lanka, but this country also had 7 of the lowest median drug prices. Pakistan had 5 of the highest and 7 of the lowest prices. Only India did not have a mix of highest and lowest prices (Table 2). Nevertheless, there was no overall difference among the SAARC countries (Friedman test c2[4] = 1.833, P = .766). Because of the large differences among the economies of the SAARC countries, it was decided that a fairer comparison would take into account the GDP per capita. The GDP-adjusted median drug prices are given in Table 3. The adjusted prices showed a more polarized picture, with Nepal generally having the highest
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Table 3. GDP-adjusted prices using median US dollar prices 3 100 000/GDP. Drug name
Bangladesh Alprazolam Amikacin
Kruskal-Wallis P value
Median Prices in US$ x 100,000/GDP India
Nepal
1.8
1.4
3.0
Pakistan 2.7
Sri Lanka 1.7
< .001
41.2
54.2
52.3
78.3
39.8
< .001
Amiodarone
8.9
8.6
18.9
19.3
9.2
0.010
Amlodipine
5.3
3.1
5.1
4.7
0.9
< .001
Amoxicillin
5.3
5.9
11.9
4.6
1.2
< .001
Atorvastatin
< .001
13.3
9.9
17.1
14.4
1.5
Baclofen
7.1
6.6
20.5
2.6
3.9
0.004
Carbamazepine
3.1
1.5
3.2
2.1
1.2
< .001
Carbimazole
2.7
1.6
2.8
0.6
0.3
0.067
Carvedilol
7.1
5.1
21.5
9.5
2.0
< .001
35.4
38.6
62.3
27.9
11.9
< .001
Clomiphene
6.0
5.1
14.8
13.5
7.0
< .001
Clopidogrel
8.9
4.8
10.8
8.8
2.5
< .001
193.8
138.8
374.4
135.8
82.8
Donepezil
8.9
7.7
16.2
8.5
7.0
0.001
Fexofenadine
7.5
7.4
16.2
9.4
2.6
< .001
17.7
16.5
32.3
86.4
6.6
< .001
Clarithromycin
Deferoxamine
Fluconazole Furosemide
–
2.9
2.6
6.5
2.1
2.0
0.032
Ipratropium Bromide
177.0
115.7
306.0
136.2
106.0
0.034
Latanoprost
696.3
305.5
1058.6
260.7
105.2
0.020
Levofloxacin
88.5
103.6
275.3
148.7
68.5
< .001
Methylprednisolone
95.5
88.8
250.0
123.6
22.3
0.208
Risperidone
4.9
3.3
12.9
21.9
1.2
< .001
Valsartan
8.4
10.7
25.8
9.4
11.2
0.409
Note. The lowest prices for each drug are highlighted in yellow, and the highest are highlighted in blue. The final column gives P values for one-way Kruskal-Wallis analyses. Those P values highlighted in pink are P < .05. GDP indicates gross domestic product.
prices (19 out of 24 drugs) and Sri Lanka having the lowest (19 out of 24 drugs). There were considerable differences between the median prices across countries. Figure 1 illustrates these differences by plotting the ratio of the country with the highest median price with the lowest median price. The ratio varied from 2 for amikacin to over 18 for risperidone. Kruskal-Wallis ANOVAs of the GDP-adjusted median prices produced even more statistically significant differences (20 out of 23 drugs, see the last column of Table 3). Figure 2 gives the median GDP-adjusted price for each country across all 24 drugs. A Friedman test produced a highly significant overall difference between different countries (c2[4] = 59.03, P , .001). Follow-up pairwise comparisons, using Bonferroni correction for 10 multiple comparisons (P , .005), revealed that Nepal had significantly higher GDP-adjusted prices compared with all the other countries and that Sri Lanka had significantly lower prices compared with all the other countries. None of the remaining 3 countries (Bangladesh, India, and Pakistan) differed significantly from each other.
Discussion Economic evaluations today have become an integral component of health services research.22 Medications are a major
item of health expenditures. The amount spent only on drugs is a point of concern even in rich countries.23 According to WHO, drugs account for 20% to 60% of healthcare expenditures in developing countries.24 An accurate measurement of crossnational price differences for drugs is an important policy and research issue. Cross-national comparisons of drug prices are often used to evaluate the performance of different regulatory systems. The SAARC is the regional organization of 8 South Asian nations. These nations have a common historical heritage and share many cultural and economic characteristics. They also have little or no concept of health insurance. In these countries, a restricted range of medications are provided in public sector hospitals procured by the state. Although patients can access essential medicines in the public sector, either free of charge or with a modest copayment, they have to purchase drugs in the private sector out of their own pocket.25,26 In one study, it was shown that medicine costs to individuals in developing countries could lead to the impoverishment of large numbers of people.27 Therefore this study was conducted to determine and compare the prices of selected drugs in countries of the SAARC. To the best of our knowledge, this is the first study in this area. To compare the retail prices, a basket of drugs was prepared based on the criteria given in the Methods section. This basket was
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Figure 1. The ratios between the highest and the lowest median gross domestic product-adjusted prices for each drug.
purely subjective; however, care was taken to ensure that it contained medications that cut across pharmacological classes of drugs used in the highly prevalent disorders in the SAARC countries.
Our findings revealed no particular pattern regarding the high variability in price differences among the SAARC countries. Nevertheless, certain interesting observations were noted. After converting all the prices into one international currency, initial
Figure 2. Median gross domestic product-adjusted prices for each country across all drugs. Nepal had the highest prices, and Sri Lanka had the lowest.
The asterisks indicate that all other countries were significantly different at P , .005 (using Bonferroni adjustment for multiple comparisons).
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price comparisons were made with the crude prices sold in the retail market. Of all 24 selected drugs, Sri Lanka topped the list with having the highest prices for 12 drugs followed by Pakistan (5), Bangladesh (3), India (2), and Nepal (2). Interestingly, when we compared the cross-national comparison of lowest prices, both Sri Lanka and Pakistan topped with lowest prices of 7 drugs each. This was followed by Nepal and Bangladesh with lowest prices of 6 and 4 drugs, respectively. After this preliminary analysis, a price comparison of the selected drugs was made after normalization of prices with the GDP of the country. This refined analysis revealed a more polarized picture in terms of drug prices. In this analysis, Nepal turned out to be the most expensive country and Sri Lanka the cheapest country for median medicine prices. Having observed the marked differences in drug prices among SAARC countries, the next logical question that needs to be explored is how prices of drugs are fixed in SAARC countries. Medicine prices in a country are the result of several pricing policies and reimbursement strategies. It was not in the scope of our study to assess whether specific pricing policies (that is, external price referencing versus value-based pricing) were more successful in driving prices down. The issue of who pays, however, is an important one from a public health perspective. A fundamental way of guiding public authorities to decide on the prices of medications is external price referencing.28 External price referencing is the practice of using the prices of medications in one or more countries to set a reference point to negotiate the price.29 This is the most commonly used pricing policy in Europe (applied by 24 out of 28 European countries).4,29 This becomes more pertinent when the economies of the referenced countries are somewhat similar. In the context of SAARC countries, the huge difference in GDP resulted in converting Nepal to the most expensive country after normalization of median prices with the GDP. These results indicated the disparity in healthcare resource allocation. The regulation of drug prices by the Ministries is not transparent. The findings of this study call for a suitable policy of price-fixing of medicines, keeping in mind the purchasing power of the population. There are some strengths of this study. Previous studies have shown the comparison of prices at the manufacturer level,12 which does not indicate the actual spending of end users because of the differences in the distribution costs and the profit of retail outlets. This problem was avoided by taking into account the retail prices of the drugs. This study also took into consideration one important confounding factor. Prices were compared for drugs that came in the same strength and same pack size in all the countries. It has been observed that the price of medications in bulk packs are generally cheaper. Therefore this confounding factor was eliminated. Nevertheless, this study has some limitations. For one thing, the list of drugs was not very large, although it included a range of medicines addressing different indications and routes of administration. This small sample size of only 24 drugs could not be representative of the actual state of affairs regarding the drug prices. Therefore caution is required when generalizing the results of this study. For another thing, the data collection duration was spread over 3 months. It is likely that prices might have changed to some extent during or soon after that. Additionally, the economy of all the sampling countries is volatile and the exchange rate with international currencies vary widely from day to day. To have minimal variation, we froze the currency conversion rate in the middle of the data collection period. Finally, in this study, the retail prices of the selected drugs were taken into account. Nevertheless, at some places, discounts are offered to end users. Therefore, it is likely that the actual transaction prices were
somewhat low; however, this will not affect the comparison across the study countries since the discounts would be available in all the study countries.
Conclusions Prices of selected drugs varied markedly in SAARC countries. At face value, Sri Lanka was found to have the highest prices of selected drugs. Nevertheless, the same drugs are sold at the highest prices in Nepal after adjusting the median prices with the GDP. When fixing the prices of the drugs, the GDP and the purchasing power of the population needs to be taken into account.
Acknowledgments The authors have no other financial relationships to disclose.
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Contents lists available at sciencedirect.com Journal homepage: www.elsevier.com/locate/vhri
Comparative Analysis of Prescription Drug Prices in South Asian Association for Regional Cooperation Countries Dileep K. Rohra, MBBS, PhD,1,* Omar A. Abuomar, MBBS,1 Peter M.B. Cahusac, PhD,1,2 Angela Dangol, MBBS,3 Priyanga Ranasinghe, MBBS4 1 Department of Pharmacology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; 2Department of Comparative Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; 3Nepal Medical College, Kathmandu University, Jorpati, Kathmandu, Nepal; 4Department of Pharmacology, University of Colombo, Colombo, Sri Lanka
A B S T R A C T Objectives: The SAARC (South Asian Association for Regional Cooperation) is a geopolitical organization composed of 8 neighboring countries: Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka. The objective of this study was to compare the prices of some selected drugs in SAARC countries. Methods: A list of 24 drugs was prepared based on certain inclusion and exclusion criteria. The retail prices of the drugs were determined from different sources and verified manually in the open market. The prices obtained in local currencies were converted into US dollars for comparison purposes. In another analysis, the gross domestic product (GDP) of each country was factored for comparative analysis. Results: Out of the 23 drugs, 17 comparisons across countries were statistically different at P , .05. These analyses revealed large differences in drug prices among SAARC countries. The GDP-adjusted median drug prices revealed a more polarized picture, with Nepal generally having the highest prices (19 out of 24 drugs) and Sri Lanka having the lowest (19 out of 24 drugs). For example, the widely used antipsychotic drug risperidone was 7 times more expensive in Pakistan ($0.316) compared with Sri Lanka ($0.045). Adjusting for GDP made risperidone more than 18 times more expensive ($21.90 and $1.20) across the same 2 countries. Conclusion: Prices of selected drugs varied markedly in SAARC countries. After adjusting for GDP, drug prices became more polarized across countries, with Nepal featuring the highest prices. In determining drug prices, the country’s GDP and the population’s purchasing power need to be taken into account. Keywords: SAARC, South Asia, drug price. VALUE IN HEALTH REGIONAL ISSUES. 2020; 21(C):113–119
Introduction The right to health is a fundamental human right, which includes access to medicine.1 A crucial factor that determines the accessibility and affordability of a medication is its price. According to the World Health Organization (WHO), policy makers should apply schemes to manage medicine prices, ensuring that citizens can easily access necessary medications.2 Medications are considered a public health product and therefore, in several countries, are funded completely or partially by the government.3 The prices of drugs are set by the pharmaceutical companies, which are regulated by the government authorities and national industry policies.4 Owing to differences in governmental policies
and pharmaceutical industry approaches, the prices of medications differ from country to country.5 Prices can also vary between countries owing to differences in the manufacturer prices or the pharmacy retail prices.4 Some medications might be relatively inexpensive but, with taxation, the consequent price for the end user becomes inordinately expensive. Cross-national price comparisons is a method used by various pharmaceutical companies and governments to set an average price level for different medications. This involves a comparison being done among diverse product samples.6 Research conducted recently to determine the differences of certain medicine prices in 16 different European countries and New Zealand showed that there was great variation.7 The differences were thought to be
Conflict of interest: The authors have indicated that they have no conflicts of interest with regard to the content of this article. * Address correspondence to: Dileep Kumar Rohra, MBBS, PhD, Department of Pharmacology, College of Medicine, Alfaisal University, P.O Box 50927, Riyadh 11533, Saudi Arabia. Email: [email protected] 2212-1099/$36.00 - see front matter ª 2019 ISPOR–The professional society for health economics and outcomes research. Published by Elsevier Inc. https://doi.org/10.1016/j.vhri.2019.09.004
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attributed to national pricing, reimbursement policies, and the economic situation of each country.7 The SAARC (South Asian Association for Regional Cooperation) is a geopolitical organization composed of 8 countries: Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka. Almost a quarter of the world population lives in these 8 countries.8 In the published literature, there are several studies that have compared drug prices across countries. Europe and North America feature strongly in these studies.9-15 To date, no study has looked at a comparative analysis of drug prices in the SAARC region. Therefore this study was conducted with the aim of comparing the prices of selected drugs in SAARC countries.
Methods Selection of Countries The SAARC consists of 8 countries. Out of these, 3 countries (Afghanistan, Bhutan, and the Maldives) do not have their own established pharmaceutical industry. Instead, they heavily rely on the supply of drugs from neighboring countries like India and Pakistan. We could not find any online database on the drug pricing in those countries; we also could not find a collaborator to help us in data collection in those countries. Therefore, those 3 countries were excluded from the study and the data of drug prices were collected from the remaining 5 countries.
Table 1. List of selected drugs analyzed for price. Drug name (INN)
Determination of Drug Prices With the objective of collecting accurate and comprehensive data on drug prices, different strategies were used for each country: 1. Bangladesh: A digital database, BDDrugs, is dedicated to providing detailed pharmaceutical information such as properties, brand and generic name, dosage form, manufacturer, and the price of the product.16 The prices of a few randomly selected products were confirmed from the open market in Dhaka to check the accuracy of the website. This exercise confirmed the reliability of the data obtained from the website. 2. India: There are various online resources, which provide the pricing information of drugs available in India. We wanted to use a database that was comprehensive and reliable. For this purpose, the source that retrieved the greatest number of brands available in India was selected.17 This showed that the database was comprehensive and retrieved most or all of the registered drugs. For the purpose of reliability and accuracy, the prices of some randomly selected drugs were checked in the open market of Ahmedabad, India, which matched those mentioned on the online source.
Selected presentation
1. Alprazolam
Benzodiazepine
0.5 mg oral
2. Amikacin
Aminoglycoside antibiotic
500 mg Injection
3. Amiodarone
Anti-arrhythmic
200 mg oral
4. Amlodipine
Ca21 channel blocker
10 mg oral
5. Amoxicillin
Penicillin antibiotic
500 mg Cap
6. Atorvastatin
HMG-CoA reductase inhibitor
20 mg oral
7. Baclofen
Skeletal muscle relaxant 10 mg oral
8. Carbamazepine
Anti-epileptic
9. Carbimazole
Antithyroid
5 mg oral
10. Carvedilol
Beta blocker
25 mg oral
11. Clarithromycin
Macrolide antibiotic
500 mg oral
12. Clomiphene
Estrogen receptor antagonist
50 mg oral
13. Clopidogrel
Antiplatelet
75 mg oral
14. Deferoxamine
Iron chelating agent
500 mg injection
15. Donepezil
Acetylcholine esterase inhibitor
5 mg oral
16. Fexofenadine
Second generation H1-receptor antagonist
180 mg oral
17. Fluconazole
Azole antifungal
150 mg oral
18. Frusemide
Loop diuretic
20 mg injection
19. Ipratropium
Antimuscarinic
40 ug/dose aerosol
20. Latanoprost
PG F2a analog
50 ug/mL eye drops
21. Levofloxacin
Fluoroquinolone antibiotic
500 mg infusion
Selection of Drugs The selection of the drugs was purely subjective; however, there were some guiding principles that were applied when finalizing the list of drugs for analysis. The list had to contain a mix of drugs from diverse pharmacological classes and with diverse clinical uses. They had to be generally widely used, come from a range of prices (from high to low), and represent multiple routes of administration. Based on these criteria, a list of 32 medications was generated. The final inclusion criterion, however, was the availability of the same drug in the open market, in exactly the same strength and presentation (pack size) in all 5 countries. This step excluded 8 drugs, leaving a final list of 24 medications (Table 1). The data of drug prices were collected for the brands available regardless of the innovator company or the generics.
Pharmacological class
22. Methylprednisolone Glucocorticoid
200 mg oral
40 mg/mL injection
23. Risperidone
Antipsychotic
4 mg oral
24. Valsartan
AT-II receptor blocker
80 mg oral
INN indicates International nonproprietary name.
3. Nepal: Because there is no online resource for retrieving the data on drugs, officials of the Department of Drug Administration in Nepal were personally approached. Data on the prices of available brands of the selected drugs were obtained from them. 4. Pakistan: For Pakistan, PharmaGuide was consulted, which is the most widely used resource for a quick reference on all the medicine available in Pakistan.18 The print version of the manual is published annually. 5. Sri Lanka: Brands available for a particular drug were identified by searching the Sri Lanka National Medicines Regulatory Authority (NMRA) website, which hosts an online database19 containing the relevant information, including the brand name and manufacturer. The prices of some drugs were checked in the open market of Colombo, Sri Lanka and double-verified. All the data were collected from November 2017 to March 2018.
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Table 2. Median drug prices in US dollars for each drug. Drug name
Kruskal-Wallis P value
Median prices in US dollars Bangladesh
India
Nepal
Pakistan
Sri Lanka
Alprazolam
0.024
0.024
0.022
0.039
0.064
< .001
Amikacin
0.559
0.927
0.381
1.130
1.525
< .001
Amiodarone
0.120
0.147
0.137
0.278
0.354
0.022
Amlodipine
0.072
0.053
0.037
0.068
0.033
< .001
Amoxicillin
0.072
0.101
0.086
0.067
0.048
< .001
Atorvastatin
0.180
0.170
0.125
0.208
0.059
< .001
Baclofen
0.096
0.112
0.149
0.038
0.151
0.006
Carbamazepine
0.042
0.025
0.024
0.030
0.044
0.002
Carbimazole
0.036
0.028
0.020
0.009
0.010
0.307
Carvedilol
0.096
0.086
0.157
0.137
0.076
0.002
Clarithromycin
0.481
0.660
0.454
0.402
0.457
< .001
Clomiphene
0.081
0.086
0.108
0.195
0.267
< .001
Clopidogrel
0.120
0.082
0.079
0.127
0.094
< .001
Deferoxamine
2.633
2.373
2.730
1.960
3.176
–
Donepezil
0.120
0.132
0.118
0.122
0.269
0.002
Fexofenadine
0.102
0.126
0.118
0.136
0.101
0.003
Fluconazole
0.241
0.283
0.236
1.247
0.254
< .001
Furosemide
0.040
0.044
0.047
0.030
0.077
0.246
Ipratropium Bromide
2.406
1.978
2.231
1.966
4.065
0.092
Latanoprost
9.461
5.224
7.719
3.764
4.034
0.183
Levofloxacin
1.203
1.772
2.007
2.147
2.629
< .001
Methylprednisolone
1.297
1.518
1.823
1.785
0.857
0.498
Risperidone
0.066
0.057
0.094
0.316
0.045
< .001
Valsartan
0.114
0.183
0.188
0.136
0.430
0.072
Note. The lowest prices for each drug are highlighted in yellow, and the highest are highlighted in blue. The final column gives P values for one-way Kruskal-Wallis analyses. Those P values highlighted in pink are P < .05.
Data Analysis All the data on prices from the SAARC countries were obtained in their local currencies. For each country, their currency value in US dollars was averaged across daily exchange rates over the month of January 2018, using the website.20 Rates obtained were as follows (giving local currencies for $1.00): 83.14 Bangladeshi Takas; 63.63 Indian Rupees; 101.83 Nepalese Rupees; 110.64 Pakistan Rupees; 153.76 Sri Lanka Rupees. This allowed all prices to be converted to US dollars. Because prices may depend on the level of gross domestic product (GDP) per capita for each country, this was factored in to some of the calculations. Country GDP per capita data were accessed from the database of the World Bank.21 All drug prices were then converted to GDP-adjusted prices using the following formula: GDP adjusted price ¼ 100 000 3 Cost US$=GDP per capita (The 100 000 constant multiplier was included to reduce the number of decimal places needed to express the values, giving a range of 0.271 to 1167.738). Preliminary parametric analyses revealed widespread heterogeneity of variances in ANOVAs, justifying the use of nonparametric analyses and the calculation of median values for more robust statistics. The following nonparametric analyses were used: Kruskal-Wallis, Friedman repeated measures, and Wilcoxon
signed ranks test. Data were entered into Excel sheets and analyzed using SPSS (IBM Corp, version 21).
Results Median drug prices in US dollars for each country are given in Table 2. Highest and lowest median prices per drug are highlighted. The last column of Table 2 gives the P values obtained from Kruskal-Wallis ANOVAs for each of the 23 drugs (deferoxamine was excluded because it had only 1 brand in each of the countries). Out of the 23 drugs, 17 comparisons across countries were statistically different at P , .05 (many were P , .001). These analyses revealed large differences in drug prices among SAARC countries. For example, 12 of the drugs with the highest median prices were in Sri Lanka, but this country also had 7 of the lowest median drug prices. Pakistan had 5 of the highest and 7 of the lowest prices. Only India did not have a mix of highest and lowest prices (Table 2). Nevertheless, there was no overall difference among the SAARC countries (Friedman test c2[4] = 1.833, P = .766). Because of the large differences among the economies of the SAARC countries, it was decided that a fairer comparison would take into account the GDP per capita. The GDP-adjusted median drug prices are given in Table 3. The adjusted prices showed a more polarized picture, with Nepal generally having the highest
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Table 3. GDP-adjusted prices using median US dollar prices 3 100 000/GDP. Drug name
Bangladesh Alprazolam Amikacin
Kruskal-Wallis P value
Median Prices in US$ x 100,000/GDP India
Nepal
1.8
1.4
3.0
Pakistan 2.7
Sri Lanka 1.7
< .001
41.2
54.2
52.3
78.3
39.8
< .001
Amiodarone
8.9
8.6
18.9
19.3
9.2
0.010
Amlodipine
5.3
3.1
5.1
4.7
0.9
< .001
Amoxicillin
5.3
5.9
11.9
4.6
1.2
< .001
Atorvastatin
< .001
13.3
9.9
17.1
14.4
1.5
Baclofen
7.1
6.6
20.5
2.6
3.9
0.004
Carbamazepine
3.1
1.5
3.2
2.1
1.2
< .001
Carbimazole
2.7
1.6
2.8
0.6
0.3
0.067
Carvedilol
7.1
5.1
21.5
9.5
2.0
< .001
35.4
38.6
62.3
27.9
11.9
< .001
Clomiphene
6.0
5.1
14.8
13.5
7.0
< .001
Clopidogrel
8.9
4.8
10.8
8.8
2.5
< .001
193.8
138.8
374.4
135.8
82.8
Donepezil
8.9
7.7
16.2
8.5
7.0
0.001
Fexofenadine
7.5
7.4
16.2
9.4
2.6
< .001
17.7
16.5
32.3
86.4
6.6
< .001
Clarithromycin
Deferoxamine
Fluconazole Furosemide
–
2.9
2.6
6.5
2.1
2.0
0.032
Ipratropium Bromide
177.0
115.7
306.0
136.2
106.0
0.034
Latanoprost
696.3
305.5
1058.6
260.7
105.2
0.020
Levofloxacin
88.5
103.6
275.3
148.7
68.5
< .001
Methylprednisolone
95.5
88.8
250.0
123.6
22.3
0.208
Risperidone
4.9
3.3
12.9
21.9
1.2
< .001
Valsartan
8.4
10.7
25.8
9.4
11.2
0.409
Note. The lowest prices for each drug are highlighted in yellow, and the highest are highlighted in blue. The final column gives P values for one-way Kruskal-Wallis analyses. Those P values highlighted in pink are P < .05. GDP indicates gross domestic product.
prices (19 out of 24 drugs) and Sri Lanka having the lowest (19 out of 24 drugs). There were considerable differences between the median prices across countries. Figure 1 illustrates these differences by plotting the ratio of the country with the highest median price with the lowest median price. The ratio varied from 2 for amikacin to over 18 for risperidone. Kruskal-Wallis ANOVAs of the GDP-adjusted median prices produced even more statistically significant differences (20 out of 23 drugs, see the last column of Table 3). Figure 2 gives the median GDP-adjusted price for each country across all 24 drugs. A Friedman test produced a highly significant overall difference between different countries (c2[4] = 59.03, P , .001). Follow-up pairwise comparisons, using Bonferroni correction for 10 multiple comparisons (P , .005), revealed that Nepal had significantly higher GDP-adjusted prices compared with all the other countries and that Sri Lanka had significantly lower prices compared with all the other countries. None of the remaining 3 countries (Bangladesh, India, and Pakistan) differed significantly from each other.
Discussion Economic evaluations today have become an integral component of health services research.22 Medications are a major
item of health expenditures. The amount spent only on drugs is a point of concern even in rich countries.23 According to WHO, drugs account for 20% to 60% of healthcare expenditures in developing countries.24 An accurate measurement of crossnational price differences for drugs is an important policy and research issue. Cross-national comparisons of drug prices are often used to evaluate the performance of different regulatory systems. The SAARC is the regional organization of 8 South Asian nations. These nations have a common historical heritage and share many cultural and economic characteristics. They also have little or no concept of health insurance. In these countries, a restricted range of medications are provided in public sector hospitals procured by the state. Although patients can access essential medicines in the public sector, either free of charge or with a modest copayment, they have to purchase drugs in the private sector out of their own pocket.25,26 In one study, it was shown that medicine costs to individuals in developing countries could lead to the impoverishment of large numbers of people.27 Therefore this study was conducted to determine and compare the prices of selected drugs in countries of the SAARC. To the best of our knowledge, this is the first study in this area. To compare the retail prices, a basket of drugs was prepared based on the criteria given in the Methods section. This basket was
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Figure 1. The ratios between the highest and the lowest median gross domestic product-adjusted prices for each drug.
purely subjective; however, care was taken to ensure that it contained medications that cut across pharmacological classes of drugs used in the highly prevalent disorders in the SAARC countries.
Our findings revealed no particular pattern regarding the high variability in price differences among the SAARC countries. Nevertheless, certain interesting observations were noted. After converting all the prices into one international currency, initial
Figure 2. Median gross domestic product-adjusted prices for each country across all drugs. Nepal had the highest prices, and Sri Lanka had the lowest.
The asterisks indicate that all other countries were significantly different at P , .005 (using Bonferroni adjustment for multiple comparisons).
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price comparisons were made with the crude prices sold in the retail market. Of all 24 selected drugs, Sri Lanka topped the list with having the highest prices for 12 drugs followed by Pakistan (5), Bangladesh (3), India (2), and Nepal (2). Interestingly, when we compared the cross-national comparison of lowest prices, both Sri Lanka and Pakistan topped with lowest prices of 7 drugs each. This was followed by Nepal and Bangladesh with lowest prices of 6 and 4 drugs, respectively. After this preliminary analysis, a price comparison of the selected drugs was made after normalization of prices with the GDP of the country. This refined analysis revealed a more polarized picture in terms of drug prices. In this analysis, Nepal turned out to be the most expensive country and Sri Lanka the cheapest country for median medicine prices. Having observed the marked differences in drug prices among SAARC countries, the next logical question that needs to be explored is how prices of drugs are fixed in SAARC countries. Medicine prices in a country are the result of several pricing policies and reimbursement strategies. It was not in the scope of our study to assess whether specific pricing policies (that is, external price referencing versus value-based pricing) were more successful in driving prices down. The issue of who pays, however, is an important one from a public health perspective. A fundamental way of guiding public authorities to decide on the prices of medications is external price referencing.28 External price referencing is the practice of using the prices of medications in one or more countries to set a reference point to negotiate the price.29 This is the most commonly used pricing policy in Europe (applied by 24 out of 28 European countries).4,29 This becomes more pertinent when the economies of the referenced countries are somewhat similar. In the context of SAARC countries, the huge difference in GDP resulted in converting Nepal to the most expensive country after normalization of median prices with the GDP. These results indicated the disparity in healthcare resource allocation. The regulation of drug prices by the Ministries is not transparent. The findings of this study call for a suitable policy of price-fixing of medicines, keeping in mind the purchasing power of the population. There are some strengths of this study. Previous studies have shown the comparison of prices at the manufacturer level,12 which does not indicate the actual spending of end users because of the differences in the distribution costs and the profit of retail outlets. This problem was avoided by taking into account the retail prices of the drugs. This study also took into consideration one important confounding factor. Prices were compared for drugs that came in the same strength and same pack size in all the countries. It has been observed that the price of medications in bulk packs are generally cheaper. Therefore this confounding factor was eliminated. Nevertheless, this study has some limitations. For one thing, the list of drugs was not very large, although it included a range of medicines addressing different indications and routes of administration. This small sample size of only 24 drugs could not be representative of the actual state of affairs regarding the drug prices. Therefore caution is required when generalizing the results of this study. For another thing, the data collection duration was spread over 3 months. It is likely that prices might have changed to some extent during or soon after that. Additionally, the economy of all the sampling countries is volatile and the exchange rate with international currencies vary widely from day to day. To have minimal variation, we froze the currency conversion rate in the middle of the data collection period. Finally, in this study, the retail prices of the selected drugs were taken into account. Nevertheless, at some places, discounts are offered to end users. Therefore, it is likely that the actual transaction prices were
somewhat low; however, this will not affect the comparison across the study countries since the discounts would be available in all the study countries.
Conclusions Prices of selected drugs varied markedly in SAARC countries. At face value, Sri Lanka was found to have the highest prices of selected drugs. Nevertheless, the same drugs are sold at the highest prices in Nepal after adjusting the median prices with the GDP. When fixing the prices of the drugs, the GDP and the purchasing power of the population needs to be taken into account.
Acknowledgments The authors have no other financial relationships to disclose.
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