ALKAN HEALTH SCIENCE, BUSINESS

AND

TECHNOLOGY COLLAGE

COLLEGE OF HEALTH AND MEDICAL SCIENCES,

DEPARTMENT OF CLINICAL PHARMACY

AVAILABILITY, PRICING AND AFFORDABILITY OF COMMONLY PRESCRIBED

ANTIMICROBIAL AGENTS IN SELECTED COMMUNITY PHARMACIES OF ADDIS
ABABA, ETHIOPIA

BY: 1. JILALU SEMAN MOHAMMED

2. JIBRIL DULA NEGASH

A RESEARCH PROPOSAL TO BE SUBMITTED TO THE COLLEGE OF HEALTH

AND MEDICAL SCIENCES, DEPARTMENT OF CLINICAL PHARMACY, IN PAR-
TIAL FULFILMENT OF BACHELOR OF DEGREE IN CLINICAL PHARMACY

JULY, 2022

ADDIS ABABA ETHIOPIA

 ALKAN HEALTH SCIENCE, BUSINESS

AND

TECHNOLOGY COLLAGE

DEPARTMENT OF CLINIC PHARMACY

AVAILABILITY, PRICING AND AFFORDABILITY OF COMMONLY PRE-

SCRIBED ANTIMICROBIAL AGENTS IN SELECTED COMMUNITY PHARMA-
CIES OF ADDIS ABABA ETHIOPIA

BY: 1. JILALU SEMAN MOHAMMED

2. JIBRIL DULA NEGASH

UNDER SUPERVISION OF: Minimize Hassen Yimer (MSc in Clinical Pharmacy)

 Acknowledgement
First of all, we would like to thank our creator and sustainer Allah and may peace and bless-
ings be upon the final prophet Muhammad who helped us in every step of this research and
for the whole of our life. Secondly, we deeply acknowledge the School of Pharmacy College
of Health and Medical Sciences for providing such a chance to study and offering technical
support and assigning advisors timely. Finally, we would like to express my gratitude to my
advisor Minimize Hassen (MSc in Clinical Pharmacy) for his desirable effort in giving us
guidance comments, suggestions and corrections on our research. We would like to thank the
pharmacy professionals of private pharmacy owners and workers for their cooperation in this
study. We would like to thank our family for their help throughout my entire life and for be-
lieving in us, and our friends for encouraging us to do well in our academic work.

I
 Abstract
Background

Drug prices and drug expenditures have become a major issue in the past few years in
developing countries and health care policymakers are concerned that their countries are
carrying a heavier burden than others in paying for drugs.

Objective

The main objective of this study was to assess the availability, price, and affordability of anti-
microbial agents in selected community pharmacies in Addis Ababa.

Method

A total of twenty (20) community pharmacies were surveyed to assess availability, price and
affordability of antibacterial agents in Addis Ababa Addis Ketema sub city. A convenient
sampling technique was employed.

Result

The mean availability of antimicrobial agents was 36.67%. From the available products 26
have very low availability (which is < 26%), 7 have low availability (which is between 26%
and 50%), 8 have fairly high availability (which is between 51% and 75%), and the rest 11
were highly available (which is > 75%). The mean affordability of antibacterial agents was
17.52 days wage.

Conclusion

In community pharmacies, antibacterial agents were more available and less affordable.
Some products were expensive in private sectors and some were completely absent.
Treatment by antibacterial agents is unaffordable by both OB and LPG products, those OB
products require high wage days than LPG products.

Keywords: Affordability, Pricing, Availability, Antimicrobial agents

II
 Contents
Acknowledgement .......................................................................................................................... I

List of Tables ................................................................................................................................ V

Abbreviations .............................................................................................................................. VI

1. Introduction ............................................................................................................................... 1

1.1. Background ............................................................................................................................ 1

1.2. Statement of the Problem ............................................................................................. 2

1.3 Significance of the Study ............................................................................................... 3

1.4 Objectives ........................................................................................................................ 4

1.4.1. General Objective ................................................................................................... 4

1.4.2. Specific Objectives .................................................................................................. 4

2. Literature Review ..................................................................................................................... 5

2.1. Availability of Anti-Microbial Agents ......................................................................... 5

2.2. Price of Anti-Microbial Agents .................................................................................... 5

2.3. Affordability of Anti-Microbial Agents....................................................................... 7

3. Methodology .............................................................................................................................. 9

3.1. Study Area and Period .................................................................................................. 9

3.2. Study Design .................................................................................................................. 9

3.3. Study Population ........................................................................................................... 9

3.3.1. Source Population ................................................................................................... 9

3.3.2. Study Population..................................................................................................... 9

3.4. Inclusion and Exclusion Criteria ................................................................................. 9

3.4.1. Inclusion Criteria .................................................................................................... 9

3.4.2. Exclusion Criteria ................................................................................................... 9

3.5. Sample Size Determination .......................................................................................... 9

3.6. Sampling Techniques .................................................................................................. 10

3.7. Data Collection ............................................................................................................ 10

III
 3.7.1. Data Collection Instrument ................................................................................. 10

3.7.2. Data Collection Technique................................................................................... 10

3.8. Study Variables ........................................................................................................... 10

3.8.1. Dependent Variables ............................................................................................ 10

3.8.2. Independent Variables ......................................................................................... 10

3.9. Data Quality Control .................................................................................................. 11

3.9.1. Data Processing and Analysis.................................................................................. 11

4. Results ...................................................................................................................................... 12

4.1. Availability of Antibacterial Agents .......................................................................... 12

4.2. Price of Antibacterial Agents ..................................................................................... 15

4.2.1. Median Price of Antibacterial Agents ................................................................ 15

4.3. Affordability of Antibacterial Agents ........................................................................ 16

5. Discussion................................................................................................................................. 18

6. Conclusion and Recommendations ....................................................................................... 20

6.1. Conclusion .................................................................................................................... 20

6.2. Recommendations ....................................................................................................... 20

References .................................................................................................................................... 21

IV
List of Tables
Table 1: Availability of 17 antibacterial agents in 30 medicine outlets of Addis Ababa
A/k/p/s.c, 2022 .............................................................................................................................. 22
Table 2: Median price and median price ratio (MPR) of available formulations surveyed in
private medicine outlets in Addis Ababa A/k/p/s.c, 2022. .......................................................... 23
Table 3: Affordability of antibacterial agents in private health care facilities of Addis Ababa
A/k/p/s.c,, 2022 ............................................................................................................................. 25

List of Figures

Figure 1: Mean availability of antibacterial agents at Addis Ababa ADDIS KETEMA SUB
CITY, 2022 .............................................................................................................................. 12

V
List of Abbreviations and Acronyms
EML Essential Medicines List

ETB Ethiopian Birr

FDRE Federal Democratic Republic of Ethiopia

HAI Health Action International

IB Innovator Brand

IRP International Reference Price

LMICs Low- and Middle-Income Countries

LPG Lowest-Priced Generic

MOH Ministry of Health

MPR Median Price Ratio

MSH Management Sciences for Health

NGO Nongovernmental Organization

OB Originator Brand

PDROs Private Drug Retail Outlets

PHCFs Public Health Care Facilities

PPs Private Pharmacies

RTI Respiratory Tract Infections

UN United Nations

WHO World Health Organization

VI
1. Introduction

1.1. Background
Access to medicines is defined as “having medicines continuously available and affordable at
public or private health facilities or medicine outlets that are within one hour’s walk from the
homes of the population.1Given its complexity, an overall picture of the degree of access to
essential medicines can only be generated using a range of proxy indicators that provide data
on medicine availability and price in both the public and the private sectors, in combination
with key policy indicators2. The availability and price of medicines are reported by the world
health organization (WHO), the United Nations (UN) and others as key measures of medicine
access. Affordability is also reported as an extension of price, and while difficult to
conceptualize and measure, it may be more directly linked to access than price alone.

One-third of the global population lacks reliable access to needed3. The situation is even
worse in the poorest countries of Africa and Asia, where as much as 50% of the population
lacks such access. While some 10 million lives a year could be saved by improving access to
essential medicines and vaccines; 4 million in Africa and South-East Asia alone; a major
obstacle to achieving this has been price3.

Average per capita spending on pharmaceuticals in high-income countries is 100 times higher
than in low-income countries about US$ 400 compared with US$ 4. WHO estimates that
15% of the world’s population consumes over 90% of the global production of
pharmaceuticals. 4

It is generally understood that large sections of the population in low- and middle-income
countries (LMICs) lack access to medicines. WHO has previously estimated that one-third of
the world’s population lacked access to essential medicines. While access to medicines is
promoted by many international health organizations and is included as an objective of
national medicines policies, it is a difficult concept to define and measure.5

Up to 90% of people purchase medicines through out-of-pocket payments making medicines

the largest family expenditure item after food. High medicine prices and poor affordability
can therefore act as a barrier to access to medicines.5

1
Access to medicines is influenced by many factors such as affordability, rational use,
sustainable financing and reliable supply systems. One of the elements restricting access to
medicines is high medicine prices. This can have a detrimental effect on patients’ health as
well as the healthcare system in terms of lack of patient compliance with treatment and
subsequent hospitalization for serious complications. To increase access to medicines, one
would thus need to ensure that medicines are affordable to counteract any existing

In Ethiopia, there are frequent drug shortages in public health care facilities (PHCFs). A
national survey estimates that, on average, only 70% of essential medicines are available in
the public sector. Unavailability of medicines in the public sector compels patients to revert
to the private sector.6

Medicines account for 20-60% of health spending in LMICs, compared with 18% in
developed countries. Drug prices and drug expenditures have become a major issue in the
past few years in developing countries and health care policymakers are concerned that their
countries are carrying a heavier burden than others in paying for drugs.7

1.2. Statement of the Problem

Prices of the same medicine are more expensive in developing countries than in industrialized
countries.8 This makes it difficult for the people in developing countries to purchase drugs,
which increases the risk of morbidity and mortality.

In developing countries, up to 90% of the population buys medicines through pocket

payments, making medication the largest family expenditure item after food. In Ethiopia, the
lowest paid government worker earns 420.00 ETB per month [Minimum wages in Ethiopia,
2021]. This makes it difficult to purchase drugs for better treatment, which increases
morbidity and mortality.

In Ethiopia, there are frequent drug shortages in public health facilities. A national survey
estimates that, on average, only 70% of essential medicines are available in the public sector 9
Unavailability of medicines in the public sector compels patients to revert to the private
sector, in which the price of the drugs is unaffordable to the patient which makes treatments
very difficult.

In our country, people use different mechanisms to treat their diseases when they cannot
afford to get the drugs, like using traditional medicines, which are not well studied and
without a well-defined dose.

2
There is a scarcity of information about the current availability, price, and affordability of
anti-microbial agents in Addis Ababa which are used to treat the prevalent infectious diseases
in the town. So, this study will help the government to focus on the price and access of these
agents in both private and public health facilities.

1.3 Significance of the Study

As there is a scarcity of information on the availability, price, and affordability of anti-
microbial agents in Addis Ababa, this study aims to be a source of information for the
responsible body to assess and control overpricing of anti-microbial agents and make them
affordable to the people. And also, it will help the government to increase access to the drugs
in public health facilities, to help the people get the right medication for treatment at an
affordable price.

3
1.4 Objectives

1.4.1. General Objective

✓ To assess the availability, price, and affordability of anti-microbial agents in selected
community pharmacies in Addis Ababa.

1.4.2. Specific Objectives

✓ To assess the availability of anti-microbial agents in selected community pharmacies
in Addis Ababa.

✓ To assess the difference in the price of anti-microbial agents between the private and
public health care facilities.

✓ To calculate the affordability of anti-microbial agents by the lowest paid government

worker in Ethiopia.

4
2. Literature Review

2.1. Availability of Anti-Microbial Agents

Availability is reported as the percentage of medicine outlets where a selected medicine was
located on the days of the survey. The availability of a group of medicines in public or private
healthcare sectors is reported using their mean % availability. To express the availability of
medicines in health care facilities, the following criteria are used. Zero % reflects the absence
of the medicine, <26% reflects very low availability, 26–50% reflects low availability, 51–
75% reflects fairly high availability, and >75% reflects high availability. The reported data
only indicate % the availability of the selected essential medicines during the data collection
period in the surveyed facilities and it doesn’t indicate the average monthly or yearly
availability of these medicines. 10
According to a study done in Odisha, India the average availability of the lowest‐priced
survey medicines in the public sector was low at 17.0%. The average availability of
lowest‐priced generics in the private sector was better than in the public sector but was still
relatively low (38.5%). Highest‐priced generic branded products were also found in the
private sector, with an average availability of 10.8%, availability of lowest‐priced generics in
NGO/mission sector facilities was similar to that of the public sector (21.8%)11.

In a study done in Swaziland, the mean availability of LPG medicines in the private sector
was 77.50% ± 27.7% compared with 68.0% ± 22.3% in the public sector, which is better than
the availability of children's medicines in Odisha. The mean availability of OB medicines
was higher in the public sector (80%) versus the private sector (40%)12.

In the survey done in Mekelle, Ethiopia, among the selected 16 essential medicines, only 10
were available in common for all public health facilities surveyed. The availabilities of the
rest of the 6 medicines were sought out only in public hospitals. The mean % availability for
all LPG was found to be 81.25%, which is higher compared to the studies done in both
Odisha and Swaziland, but as the research is done on essential medicines their availability
should be 100 %9.

2.2. Price of Anti-Microbial Agents

Price measured is patient price for the medicines in PHCFs and private drug retail outlets
(PDROs). Summary results of the patient prices noted during surveys are not expressed as

5
currency units, but rather as ratios relative to a standard set of international reference prices.
The reference prices from the Management Sciences for Health (MSH) have been selected as
the most useful standard, because they are internationally recognized. Median price ratio
(MPR) is calculated by dividing the median price of each medicine surveys by the MSH
price. The ratio is thus an expression of how much greater or less the local medicine price is
than the MSH price. Since averages can be skewed by outlying values, median values have
been used in the price analysis as a better representation of the midpoint value. The MPR of a
medicine is calculated, if it is available at least in one surveyed facilities13.

According to the WHO/HAI methodology, MPRs greater than 2.00 for LPGs would generally
be cause for concern, since this is twice the price of these medicines if procured from
international suppliers. The following ideal MPR values were used to represent reasonable
local price ratios: public health care facilities – patient price: MPR ≤ 1.5 and PDROs –
patient price: MPR ≤ 2.0.

According to a study done on availability, price, and affordability of children’s medicine in

Odisha, India, in 2010. In the public sectors, the government of Odisha provides medicines
free for the patients. Among the 14 medicines for which procurement prices were reported, it
was found that the state drug management unit is purchasing medicines at approximately half
the international reference prices MPR of 0.52 which indicates efficient purchasing. In the
private sector, lowest‐price generic medicines were being sold at 1.46 times their
international reference price. Half of the lowest‐priced medicines were priced at 1.06 to 2.29
times their international reference price, which indicates moderate variation in the median
price ratios of individual medicines. Highest‐priced products were being sold at 1.83 times
their international reference price, with similar variation across individual medicines as
observed with lowest‐priced generics. Some medicines also showed substantial variation in
the prices reported across individual private sector facilities11.

Like the government of Odisha, the government of Swaziland also gives drugs for free in
public sectors. Based on the MPRs’ results for all 16 survey medicines, the public sector was
procuring medicines at a slightly lower price than their International Reference Price (IRPs)
(median MPR = 0.96), which is higher than the procurement price of Odisha (MPR of 0.52).
Half of the lowest-priced generic medicines were priced at 0.79 (25th percentile) to 1.72 (75th
percentile) times their IRP. When private-sector medicine prices were compared with IRPs,
the OB products were found to be priced at 32.4 times the IRPs, which is very highly priced

6
when compared to price in Odisha. The median price of the lowest-priced generic equivalent
was 7.32 times the IRP price, which is also high12.

Unlike the above two countries, drugs are not for free in Ethiopia except in non-governmental
organizations (NGOs) like those which give service only for families of the military.
According to a study done in Mekelle, the core lists of generic medicines show a range of
MPR values (0.42-2.62). The supplementary list of generic medicines shows a range of MPR
values (0.56-2.4). Considering the whole selected essential medicines, only three LPGs
(18.75%) were above the acceptable MPR value (MPR ≤ 1.5) and the remaining 13 generic
medicines have acceptable MPR value. The 11 core generic medicines show a range of MPR
values (0.83-7.86). The MPR values of supplementary medicines in PPs lie within a range of
1.28-3.51. Eight LPGs (50%) were out of the reasonable MPR value (MPR ≤ 2.0) and the
remaining 8 LPGs had reasonable MPRs. The 4 Innovator Brands (IBs) were found have
extremely wide range of MPR values (2.33-44.52). Median MPR of the 4 IBs was found to
be 22.45 times the MSH reference price, which makes it 16.51 times median MPR of its
LPGs (1.36). This shows how much costly IBs were as compared to LPGs in the PPs10.

2.3. Affordability of Anti-Microbial Agents

Affordability is estimated using the salary of the lowest-paid unskilled government worker to
establish the number of days’ wages needed to purchase courses of treatment for the common
conditions for which the selected essential medicines are indicated. The cost of treatment for
acute conditions is calculated by multiplying median treatment price by number of days
required to treat the disease condition. Because chronic diseases need ongoing treatment,
affordability of a 30-day supply of medicines is used to indicate monthly medicine
expenditures. Although it is difficult to assess true affordability, treatment costing one day’s
wage or less for a full course of an acute condition and a 30-day supply of medicine for
chronic diseases are generally considered affordable.

So, without considering income variation and those people who earn below or above the
lowest paid unskilled Ethiopian government worker, the term unaffordable is used if the
disease condition requires more than one day’s wage of the lowest paid unskilled Ethiopian
government worker10.

According to the research in Odisha, the affordability of treatment for six common conditions
was estimated as the number of daysʹ wages of the lowest‐paid government worker needed to
purchase medicines prescribed at a standard dose. For acute conditions treatment duration

7
was defined as a full course of therapy, while for chronic diseases it was defined as a 30‐day
supply of medicine. The daily wage of the lowest‐paid government worker used in the
analysis was Rest. 277.42. Because of the extremely low availability of children’s medicine
in the public sector most of the patients are forced to purchase medicines from the private
sector. For this and other reasons many patients have little faith in government‐supplied
medicines. In the private sector, the affordability of both lowest‐priced and highest‐priced
generics was reasonable for all six conditions, with standard treatment costing less than a
day’s wage. Even where individual treatments appear affordable, individuals or families who
need multiple medications may quickly face unmanageable drug costs11.

The affordability of medicines in Swaziland was done only for medicines purchased from the
private sector, since the government supplies medicines for free. The affordability of the
LPGs, with the exception of enalapril, was less than one, with standard treatment costing
slightly above a day’s wage (1.2). Standard treatment with OBs cost more than a day’s wage,
except for metformin (0.9). For example, treating diabetes with glibenclamide required 6.7
days’ wages and treating hypertension with atenolol needed 4.8 days’ wages12.

According to a study done in Mekelle, Northern Ethiopia in 2011, in the public sector, for a
one-month course of LPG medicine to treat the selected chronic conditions, peptic ulcer
require the highest days' wages (2 days’ wage) of the lowest paid unskilled Ethiopian
government worker. While for acute conditions, Respiratory Tract Infection of adults requires
the highest days' wages (1.25 days’ wage) of the lowest paid unskilled government worker.
The standard treatment cost of asthma was unaffordable, but Diabetes Mellitus (DM),
Respiratory Tract infection (RTI) (in child), and intestinal amoebiasis was found affordable10.

In the private sectors, all IBs were unaffordable in PPs. To the contrary, standard treatment
costs of DM, RTI of child and intestinal amoebiasis using LPGs were affordable in these PPs.
For a one-month course of medicine to treat the selected chronic condition, peptic ulcer
require the highest days' wages in both medicine types (generic and brand).The
extraordinarily high days' wages (217.74) required to treat peptic ulcer using the IB should
obviously be the cause for great concern from acute conditions, RTI of adults require the
highest days' wages (2.06) of the lowest paid unskilled Ethiopian government worker using
LPG product. The brand premium indicates how much the IBs cost patients as compared with
their generic equivalents10.

8
 3. Methodology

3.1. Study Area and Period

The study was conducted at selected community pharmacies of Addis Ababa, which is the
capital city of Ethiopia. Addis Ababa is the capital city of Ethiopia in the high lands
bordering the great rift valley. It is the country’s commercial and cultural hub; its elevation is
2355 m accounting area of 527 km2. Addis Ababa is a humid city with average weather of
120c. Addis Ababa has a total of 308 pharmacies, 249 drug stores and 1 rural drug store in all
of the sub-cities.

3.2. Study Design

A prospective cross-sectional study was conducted to determine the availability, price, and
affordability of anti-microbial agents.

3.3. Study Population

3.3.1. Source Population

All community pharmacies found in Addis Ababa.

3.3.2. Study Population

Selected private community pharmacies found in Addis Ababa.

3.4. Inclusion and Exclusion Criteria

3.4.1. Inclusion Criteria

✓ Selected private pharmacies which are available during the study period

✓ Selected antibacterial agents from 2015 Ethiopian Essential Medicine List (EML)
which are budget products available for the patient for sale

3.4.2. Exclusion Criteria

✓ Government community pharmacies (e.g., Kenema pharmacy)

✓ Drug stores

✓ Hospital pharmacies

3.5. Sample Size Determination

Thirty (30) community pharmacies medicine were selected for the study based on the
WHO/HAI standardized sampling methodology.

9
3.6. Sampling Techniques
Convenient sampling technique was employed. On this basis, the surveyed pharmacies were
the following.

1. City med pharmacy 8. Hawera Pharmacy 15. Public pharmacy

2. Ebrayst pharmacy 9. Harer pharmacy 16. Africa pharmacy

3. Hiwot pharmacy 10. pi pharmacy 17. Addis pharmacy

4. Addis ketema 11. Mina pharmacy 18. Zright pharmacy

5. Tru pharmacy 12. Garoma Pharmacy 19. Zak pharmacy

6. Alem tena 13. Ras pharmacy 20. Hawed pharmacy

7. Helix pharmacy 14. Ahadu Pharmacy

3.7. Data Collection

3.7.1. Data Collection Instrument

Pen and pencil and a standardized data collection tools developed by WHO/HAI with
necessary modifications in line with local conditions was used to collect the data from the
facilities surveyed.

3.7.2. Data Collection Technique

Data was collected by visiting each medicine outlet.

3.8. Study Variables

3.8.1. Dependent Variables

✓ Availability of anti-microbial agents

✓ Price of anti-microbial agents

✓ Affordability of anti-microbial agents

3.8.2. Independent Variables

✓ Location of the health care facilities

✓ Monthly income of lowest paid government worker

10
3.9. Data Quality Control
The data was collected by the principal investigator using standardized format prepared by
WHO/HAI. Before starting the data collection, pre-test was done on 10% of the sample size.

3.9.1. Data Processing and Analysis

After data collection, data was entered, categorized and analyzed using statistical package for
social sciences statistics computer software package. The result was summarized and
presented in tables and graphs.

11
 4. Results
A total of twenty (20) community pharmacies were surveyed to assess availability, price and
affordability of antibacterial agents in Addis Ababa Addis Ketema sub city.

4.1. Availability of Antibacterial Agents

Mean availability is calculated by dividing the sum of % availability of antibacterial agents
by the total number of available drugs in the outlets.

Mean availability= sum of % availability of antibacterial agents/total number of available

drugs

=1906.3 %/52

=36.67 %

Mean availability of antibacterial agents in Adiss

ababa A/K/S/C

Yes
10.67
No
63.33

yes no

Figure 1: Mean availability of antibacterial agents at Addis Ababa ADDIS KETEMA SUB
CITY, 2022
Availability of each medicine is calculated by dividing the number of medicine outlets that
have the drug during data collection time by the total number of medicine outlets.

Among the surveyed 17 medicines and formulations of the medicines neomycin and
nitrofurantoin were not available in all the 20 medicine outlets. Zero % reflects the absence of
the medicine, <26% reflects very low availability, 26–50% reflects low availability, 51–75%
reflects fairly high availability, and >75% reflects high availability. The availability and
source of each medication in all 20 medicine outlets as shown in table 1 below. Source of the
products is done only for LPG products because all OB products are imported.

12
 Table 1: Availability of 17 antibacterial agents in 20 medicine outlets of Addis Ababa
ADDIS KETEMA SUB CITY, 2022

Product Availability Product Availability

Yes No Yes No
Amoxicillin 250 mg OB 20% 80% Doxycycline 100 OB 100%
capsule mg tablet
Amoxicillin 500 mg OB 100% - Doxycycline 100 OB 100%
capsule mg capsule
Amoxicillin OB 100% - Erythromycin OB 50%
125mg/5ml syrup 250mg tablet
Amoxicillin OB 100% - Erythromycin OB 80% 20%
250mg/5ml syrup 500mg tablet
Amox-clav OB 70% 30% Erythromycin OB 100% -
1256.25mg/5ml syrup 625mg
Amox-clav OB 66% 34% Erythromycin OB - 100%
228.5mg/5ml syrup 200mg/5ml syrup
Amox-clav OB 40% 60% Erythromycin OB - 100%
312.5mg/5ml syrup 250mg/5ml syrup
Amox-clav OB 50% 50% Erythromycin OB - 100%
457mg/5ml syrup 250mg capsule
Amox-clav 625mg OB 0% 100% Gentamicin OB 20% 80%
capsule 40mg/ml injection
Amox-clav 1gm OB 30% 70% Gentamicin OB 20% 80%
capsule 80mg/2ml
injection
Amox-clav 600mg OB 100% B. penicillin G 0.6 OB - 100%
injection MIU injection
Amox-clav 1.2mg OB - 100% B. penicillin G 1.2 OB 30 70%
injection MIU injection
Amox-clav 156.25mg OB - 100% B. penicillin G 2.4 OB 10% 90%
chewable tablet MIU injection
Ampicillin 250mg OB - 100% C. penicillin G 1 OB - 100%

13
 capsule MIU injection
Ampicillin 500mg OB 100% C. penicillin G 10 OB - 100%
capsule MIU injection
Ampicillin OB - 100% C. penicillin G 20 OB - 100%
125mg/5ml syrup MIU injection
Ampicillin OB - 100% PPF 4 MIU OB - 100%
250mg/5ml syrup injection
Ampicillin 250mg OB - 100% Ceftriaxone OB - 100%
injection 250mg injection
Ampicillin 500mg OB - 100% Ceftriaxone 500 OB - 100%
injection mg injection
Ampicillin 1gm OB - 100 % Ceftriaxone 1gm OB - 100%
injection injection
Cloxacillin 250mg OB 100 % Ceftriaxone 2gm OB - 100%
capsule injection
Cloxacillin 500mg OB - 100% Metronidazole OB - 100%
capsule 5mg/ml infusion
Cloxacillin 250mg OB - 100% Metronidazole OB - 100%
injection 250mg tablet
Cloxacillin 500mg OB - 100% Metronidazole OB - 100%
injection 250mg capsule
Cloxacillin 125mg OB - 100% Neomycin 500mg OB - 100%
syrup tablet
Cloxacillin OB - 100% Nitrofurantoin 50 OB - 100%
250mg/5ml injection mg capsule
Chloramphenicol OB - 100% Nitrofurantoin 100 OB - 100%
250mg capsule mg capsule
Chloramphenicol OB - 100% Nitrofurantoin OB - 100%
1gm injection 0.5% syrup
Chloramphenicol OB - 100% Tetracycline 250 OB - 100%
125mg/5ml syrup mg capsule
Amox-clav- amoxicillin-clavulinic acid; C.penicillin- crystallie penicillin; B.penicillin-
benzathine penicillin; MIU-million international unit

14
4.2. Price of Antibacterial Agents
The median price of each medicine is calculated by dividing the median price of each
medicine surveyed by the MSH price. The ratio is thus an expression of how much greater or
less the local medicine price is than the MSH price. At the day of analysis, the exchange rate
of 1 ETB was 0.0232 USD, by using this the median price of each medicine calculated.

4.2.1. Median Price of Antibacterial Agents

The median price ratio is used to know how much the drug costs compared to the IRP of the
drug. MP in private medicine outlets is done for those formulations found in the outlet at the
day of study, is shown below in table 4.

Table 2: Median price of available formulations surveyed in private medicine outlets in Ad-
dis Ababa ADDIS KETEMA SUB CITY, 2022.

Product MP(ETB) Product MP(ETB)

Amoxicillin 250mg OB 40 Chloramphenicol OB -
capsule 1gm injection
Amoxicillin 500mg OB 70 Chloramphenicol OB -
capsule 125mg/5ml syrup
Amoxicillin OB 72 Doxycycline 100mg OB 78
125mg/5ml syrup tablet
Amoxicillin OB 78 Doxycycline 100mg OB 75
250mg/5ml syrup capsule
Amox-clav OB 243 Erythromycin OB 20
156.25mg/5ml 250mg tablet
syrup
Amox-clav OB 260 Erythromycin OB 25
228.5mg/5ml syrup 500mg tablet
Amox-clav OB 310 Erythromycin OB 380
312.5mg/5ml syrup 625mg
Amox-clav OB 420 Gentamicin OB -
457mg/5ml syrup 40mg/ml injection
Amox-clav 625mg OB Gentamicin OB 15
capsule 80mg/2ml injection
Amox-clav 1gm OB B. penicillin G OB 20

15
 capsule 1.2 MIU injection
Amox-clav 600mg OB B. penicillin G OB -
injection 2.4 MIU injection
Ampicillin 250 mg OB - C. penicillin G OB -
capsule 1 MIU injection
Ampicillin 500 mg OB - PPF 4MIU injection OB -
capsule
Ampicillin OB - Ceftriaxone OB 20
125mg/5ml syrup 250mg injection
Ampicillin 500 mg OB - Ceftriaxone OB 25
injection 500mg injection
Ampicillin 1gm OB - Ceftriaxone OB 45
injection 1gm injection
Cloxacillin 250 mg OB 25 Metronidazole OB 50
capsule 5mg/ml infusion
Cloxacillin 500 mg OB 40 Metronidazole OB 30
capsule 250mg tablet
Cloxacillin 500 mg OB - Metronidazole OB -
injection 250mg capsule
Cloxacillin OB - Co-trimoxazole OB -
125mg/5ml syrup 480mg tablet
Chloramphenicol OB - Tetracycline 250 mg OB -
250mg capsule capsule

4.3. Affordability of Antibacterial Agents

Mean affordability is calculated by dividing the sum of the number of days wage that the
treatment course requires of each antibacterial agents divided by the total number of
antibacterial agents available in the medicine outlets.

Mean affordability= sum of days wage treatment requires/ total no of available drugs

=911.065/52

= 17.52 days wage

16
 Affordability of each medicine is calculated by multiplying the median price of the product
by the number of days that the treatment takes, then divided by the amount of money that the
lowest paid unskilled government worker earns per day (which is 420 ETB per month = 14
ETB per day). The number of days for the treatment course takes was taken as 10 days
because many bacterial infection treatments take 7-14 days and 10 days treatment course was
used as a mean.

Table 3: Affordability of antibacterial agents in public and private health care facilities of
Addis Ababa ADDIS KETEMA SUB CITY, 2022.

Product MP(ETB) Wage(days) Product MP(ETB) Wage (days)

Amoxicillin OB - - Chloramphenicol OB -
250mg capsule LPG 0.60 1.28 1gm injection LPG 5.00 14.28
Amoxicillin OB 6.60 14.14 Chloramphenicol OB - -
500mg capsule LPG 1.00 2.14 125mg/5ml LPG 25.00 7.14
syrup
Amoxicillin OB 62.50 15.625 Doxycycline OB - -
125mg/5ml syrup LPG 20.00 1.43 100mg tablet LPG 1.50 2.14
Amoxicillin OB 82.00 17.51 Doxycycline OB - -
250mg/5ml syrup LPG 28.00 6 100mg capsule LPG 0.70 1
Amox-clav OB 128.00 27.42 Erythromycin OB - -
156.25mg/5ml LPG 80.00 17.14 250mg tablet LPG 2.60 7.42
syrup
Amox-clav OB 124.00 26.57 Erythromycin OB - -
228.5mg/5ml syrup LPG 100.00 21.42 500mg tablet LPG 2.50 7.14
Amox-clav LPG 96.00 20.57 Erythromycin LPG 65.00 18.57
312.5mg/5ml syrup 200g/5ml syrup
Amox-clav OB 176.00 37.71 Gentamicin OB - -
457mg/5ml syrup LPG 117.50 27.15 40mg injection LPG 3.50 2.5
Amox-clav OB 22.85 48.96 Gentamicin OB - -
625mg capsule LPG 8.92 19.11 80mg injection LPG 5.00 3.57
Amox-clav OB 30.35 65.03 B. penicillin G OB - -
1gm capsule LPG 10.71 22.95 1.2MIU injection LPG 10.00 0.71
Amox-clav 600 inj. OB 28.35 60.75 B. P G 2.4 MIU OB - -

17
 LPG - - injection LPG 8.00 0.57
Ampicillin OB - - C. penicillin G OB - -
250 mg capsule LPG 0.55 1.57 1 MIU injection LPG 6.00 17.14
Ampicillin OB - - PPF 4 MIU OB - -
500 mg capsule LPG 1.00 2.85 injection LPG 12.00 3.42
Ampicillin OB - - Ceftriaxone OB - -
125mg/5ml syrup LPG 18.00 5.14 250mg injection LPG 48.00 68.57
Ampicillin OB - - Ceftriaxone OB - -
500 mg injection LPG 3.00 8.57 500mg injection LPG 58.00 82.85
Ampicillin OB - - Ceftriaxone OB - -
1gm injection LPG 20.50 58.57 1gm injection LPG 23.00 32.85
Cloxacillin OB - - Metronidazole OB - -
250 mg capsule LPG 0.70 2 5mg/ml infusion LPG 19.00 40.7
Cloxacillin OB - - Metronidazole OB - -
500 mg capsule LPG 1.20 3.42 250mg tablet LPG 9.60 20.57
Cloxacillin OB - - Metronidazole OB - -
500 mg injection LPG 10.00 28.57 250mg capsule LPG 0.50 1.07
Cloxacillin OB - - Co-trimoxazole OB - -
125mg/5ml syrup LPG 43.00 6.14 480mg tablet LPG 0.50 0.71
Cloxacillin OB - - Co-trimoxazole OB - -
250mg/5ml syrup LPG 25.00 3.57 960mg tablet LPG 0.80 1.14
Chloramphenicol OB - - Tetracycline OB - -
250mg capsule LPG 0.80 2.28 250mg capsule LPG 0.50 1.42

5. Discussion
The mean availability of antibacterial agents in private health care facilities in Addis Ababa
ADDIS KETEMA SUB CITY is median (66.4%) which is very low compared to survey done
in Odisha, India in which the mean % availability of LPG products was 81.25%, Among the
surveyed 122 formulations of 17 antibacterial agents only 52 (42.6%) were available in all 20
medicine outlets.

18
From the available products 26 have very low availability (which is < 26%) and the other 7
have low availability (which is between 26% and 50%). 8 have fairly high availability (which
is between 51% and 75%), and the rest 11 were highly available (which is > 75%). But as
compared to other African countries the availability of anti-microbial agents is higher as it
was surveyed in Cameroon which has lower availability of antimicrobials.

For the total 52 (42.62%) available agents the MPR range from 0.075 (Amox-clav 600 mg
injection) to 61.8985 (metronidazole 250 mg tablet) which indicates there is a higher
variation in the median price ratios of individual medicines. The median MPR is calculated
for 44 (84.6 %) medicines from 52 available because of IRP of 8 medicines was not available
in the MSH price list. In all public and private sectors all drugs were sold 4.005 times their
IRP by average which shows that people are incurred more cost in Addis Ababa ADDIS
KETEMA SUB CITY to get treatment with antibacterial agents when compared to the
reference price.

OB products are sold 5.54 times their IRP which is higher compared with study done in 2010
in Odisha, India in which OB products were sold 1.83 times their IRP. LPG products were
sold 3.71 times their reference price which is higher when compared with Odisha in which
LPG products were sold 1.46 times their IRP, this may be due to the large sample of this
study and lower price control in the Addis Ababa ADDIS KETEMA SUB CITY than Odisha.

In private sectors among the 48 available drugs 17 (35.4%) had reasonable local price ratio
(≤2 of IRP) the rest 31(64.6%) has higher local price ratio. The products were sold 3.545
times their IRP, which is higher and may indicate there is poor control in the pricing of
medications or it may be due to poor drug procurement system of the organizations. From OB
products only amoxicillin-clavulanic acid 600 mg injection had reasonable local price ratio
(0.79), OB were sold 5.84 times their IRP which is higher than in Odisha which is 1.83 times
their IRP, this indicates treatment by OB in Addis Ababa ADDIS KETEMA SUB CITY
require cost of drugs that is greater than their IRP, this may be due to lack of good
procurement system in the country. LPG products were sold 3.056 times their IRP in private
sectors, is also higher than in Odisha which is 1.46 times their IRP.

Only 4 products out of 52, were affordable; requires 1 or less wage day for full course of
treatment, which are doxycycline 100 mg capsule (1 day wage), B. penicillin G 1.2 MIU and

19
2.4 MIU (0.71- and 0.57-days wage respectively) and co-trimoxazole 480 mg tablet (0.71-day
wage). The number of days wage ranges from 0.57 (B. penicillin G 2.4 MIU) to 82.85
(ceftriaxone 500 mg injection). The mean affordability of antibacterial agents is 17.52 days.

In Addis Ababa ADDIS KETEMA SUB CITY 34.85 days wage is needed to be treated with
OB product, compared with research done in Shaanxi, China in 2013 treatment in public
hospitals required 9.9 days’ wages for the OB, this difference may be due to the study in
China is done in public sectors only and focuses only in essential drugs and are few in
number, and there may be good procurement system in China than Ethiopia [Jiang et al.,
2013].

Treatment by LPG products requires 13.89 days wage, when compared with a study in
Mekelle (needs 1.25 days wage to treat RTI), treatment requires higher days of wage this may
be due to the study in Mekelle is on public sectors only and focuses only in few drugs.

6. Conclusion and Recommendations

6.1. Conclusion
Based on this study, antibacterial agents have median availability in Addis Ababa ADDIS
KETEMA SUB CITY. In community pharmacies, antibacterial agents were more available
and less affordable. Some products were expensive in private sectors and some were
completely absent. Treatment by antibacterial agents in Addis Ababa ADDIS KETEMA SUB
CITY is unaffordable by both OB and LPG products, those OB products require high wage
days than LPG products.

6.2. Recommendations
According to the result of this study the following points are recommended for different
bodies:

✓ For PFSA
o To improve the availability of antibacterial agents which are not branded to
increase affordability
o To implement procurement system that can minimize the patient price of anti-
bacterial agents.
✓ To the health bureau of Addis Ababa ADDIS KETEMA SUB CITY
o To improve the availability of antibacterial agents
o To control the price of antibacterial agents in private sectors

20
References
1. UN Development group, 2003].
2. United Nations (2008). Delivering on the Global Partnership for Achieving the
Millennium Development Goals. MDG Gap Task Force Report. New York.
3. Hovland I (2005). Successful communication: a toolkit for researchers and civil
society organizations. Overseas Development Institute. London
4. World Health Organization (2004). The World Medicines Situation. Geneva,
Switzerland.
5. World Health Organization, Health Action International (2008). Measuring medicine
prices, availability, affordability and price components. 2nd ed. Geneva
6. FDRE Ministry of Health and WHO (2005). Technical Report. In: Survey on prices of
medicines in Ethiopia. Addis Ababa.
7. World Health Organization (2003). Economic aspects of drug use (Pharmaco
economy). In: Introduction to Drug Utilization Research. Oslo, Norway: p. 26.
8. World Health Organization, Health Action International (2008). Measuring medicine
prices, availability, affordability and price components. 2nd ed. Geneva
9. Anita K, et al (2007). Prices and availability of common medicines at six sites in India
using a standard methodology: Indian Journal of Medical Research 125:645–54
10. Belachew G and Yohannes M (2011). The private-public-divide on the economics of
essential medicines in Mekelle, Northern Ethiopia: a critical analysis on the national
drug policy outcomes. International Journal of Advances in Pharmaceutical
Research2(12): 630 – 638.
11. S.C.B. Medical College and Hospital, Department of Pharmacology (2010). Study
assessing prices, availability, and affordability of children’s medicine in Odisha. India
12. Brenda S and Fatima S (2014). Price availability and affordability of medicines.
African Journal of Primary Health Care & Family Medicine; Swaziland.
13. MSH and WHO, 2009. International drug price indicator guide 2009 edition.
Accessed at: (http://erc.msh.org).

21
 Annex

Alkan Health Science and Technology College

Pharmacy Department

Medicine price and availability collection form

Date: ___________

Name of the pharmacy: _________________

➢ Lively hood stage

Rich middle class poor

➢ price of the drug

expensive affordable cheap

➢ type of drug

generic Brand

➢ is there government intervention

yes no

➢ have you found the drug easily?

yes no

➢ how many pharmacies you asked for the drug

one two` more than two

➢ do you think there is a method to increase affordability?

yes no

justify if you answer yes___________________________________________

22