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Metrics details. High price is a major challenge limiting access to essential medicines especially among the poorest families in developing countries. The study aims to compare the prices of medicines used in the management of pain, diabetes, and cardiovascular diseases in private pharmacies and the National Health Insurance Fund NHIF in Tanzania. Twenty-eight essential medicines, of which 9 are used for management of pain, 7 for diabetes, and 12 for cardiovascular diseases were analyzed. There was a significant difference in the mean pharmacy prices of some medicines between the regions and between the pharmacies and NHIF reference prices. NHIF reference prices were higher than the pharmacy prices for 16 of the 28 medicines. The study found that medicine prices in private pharmacies vary a lot between the study regions, which raises equity concerns. Also, there was a significant difference between the pharmacy and the NHIF reimbursement prices, which may expose patients to fraudulent co-payments or hinder timely access to prescribed medicines. Therefore, effective price control policies and regulations for medicines are warranted in Tanzania. Over the past two decades, there has been a substantial epidemiological transition of diseases from communicable to non-communicable diseases NCDs. It is estimated that NCDs kill more than 40 million people annually, which is almost two-thirds of all deaths \\\\\\\\\\\\\[ 1 \\\\\\\\\\\\\]. The Global Burden of Disease study ranked diabetes, low back pain, and cardiovascular diseases such as ischemic heart diseases and stroke higher in the top 25 causes of disability-adjusted life years DALYs \\\\\\\\\\\\\[ 2 \\\\\\\\\\\\\]. The reasons behind the rapid epidemiological transition in developing countries have been likened to unhealthy lifestyles such as lack of physical activities, unhealthy diets, alcohol, and tobacco use \\\\\\\\\\\\\[ 4 , 5 , 6 \\\\\\\\\\\\\]. Unlike infectious diseases, NCDs such as diabetes and cardiovascular diseases do not disable a person instantly, but progress slowly and if not managed early and effectively can lead to even more severe disabling effects in the long-term \\\\\\\\\\\\\[ 7 \\\\\\\\\\\\\]. Health expenditures also increase dramatically with the increase in the number of chronic conditions affecting the patient because of the complexity of care \\\\\\\\\\\\\[ 8 \\\\\\\\\\\\\]. Thus, the long-term health costs required for the management of NCDs that often include lengthy and expensive treatments can quickly drain household resources particularly in low-income settings where out-of-pocket health payments are common \\\\\\\\\\\\\[ 9 \\\\\\\\\\\\\]. Governments in low- and middle-income countries are increasingly implementing alternative financing strategies including health insurance in an attempt to improve access to healthcare and to protect families from impoverishing health expenditures \\\\\\\\\\\\\[ 10 , 11 , 12 \\\\\\\\\\\\\]. In December , the United Nations General Assembly adopted a resolution on universal health coverage, which among other things urged countries to provide affordable and quality healthcare to all \\\\\\\\\\\\\[ 13 \\\\\\\\\\\\\]. Today, access to essential medicines remains a major challenge to a large proportion of poor sections of populations in developing countries, especially among those suffering from NCDs. This problem is exacerbated by the high prices of essential medicines, which hinder access to care \\\\\\\\\\\\\[ 14 \\\\\\\\\\\\\]. Several cost-containment measures to prevent further escalation of treatment costs have been proposed by the WHO including; regulation of mark-ups in the pharmaceutical supply chain, exemptions or reduction of tax for essential medicines, use of reference pricing, promoting the use of generics, and the use of health technology assessment to inform pricing and reimbursement decisions \\\\\\\\\\\\\[ 15 \\\\\\\\\\\\\]. Nevertheless, the lack of technical capacity, supporting policy frameworks, and relevant data have hampered the effective implementation of these cost-containment strategies in most developing countries \\\\\\\\\\\\\[ 16 , 17 , 18 \\\\\\\\\\\\\]. Tanzania is an East African country with more than 45 million people \\\\\\\\\\\\\[ 19 \\\\\\\\\\\\\]. The health system, which is largely public-owned, is organized in a pyramidal structure in which the primary health facilities are at the base and the specialized and referral hospitals are at the apex. A comprehensive network of primary healthcare facilities i. Each facility offers pharmacy services, however, due to frequent stock-outs patients often buy medicines in the private pharmacies and Accredited Drug Dispensing Outlets ADDO. The later are authorized to stock a limited list of prescription-only-medicines and are mainly located in underserved rural areas where there are no pharmacies \\\\\\\\\\\\\[ 20 \\\\\\\\\\\\\]. In , the Tanzanian government established the National Health Insurance Fund NHIF , which by then it was a compulsory health insurance scheme for serving central government employees only. However, since membership has been extended to include all public servants, private sector institutions, individuals, and their legal dependents. As of December , the number of beneficiaries was about 4. Because of this rapid increase of the beneficiaries and low availability of medicines in public health facilities, the NHIF accredits private sector health facilities including pharmacies and ADDOs to provide medicines to its members. Medicine prices in private pharmacies and drug shops are unregulated, hence prices tend to vary depending on buying price, operational cost, and profit margin desired unlike in public health facilities where prices are relatively uniform because they get most of their medical supplies from the Medical Store Department. Also, NHIF does not usually update its reimbursement rates frequently, which may take more than 3 years \\\\\\\\\\\\\[ 22 \\\\\\\\\\\\\]. This means that the actual costs incurred by providers can be much higher than the reimbursement rates, creating fraudulent co-payments that may limit timely access to prescribed medicines, and further exposing patients to catastrophic out-of-pocket health expenditures. Therefore, The study aims to compare the prices of medicines used in the management of pain, diabetes, and cardiovascular diseases in private pharmacies and the National Health Insurance Fund NHIF in Tanzania. This was a cross-sectional study, which was conducted in four regions of Tanzania, namely Dar es Salaam, which is located in the coastal zone, Morogoro and Dodoma in the central zone, and Kilimanjaro in the northern zone Fig. Data on the selected list of essential medicine was collected from 33 private pharmacies that were selected purposively from the list of the NHIF-accredited pharmacies available in the four study regions. Dar es Salaam was selected because it is the main business city in Tanzania with a total population of about 4. Among the retail private pharmacies in this region, 57 pharmacies have been accredited to provide service to NHIF beneficiaries, and only 20 pharmacies were surveyed during this study. More than half of the private pharmacies in the country are in this region. Morogoro region has a population of about 2. Morogoro had 20 retail private pharmacies, and only 4 out of 6 accredited pharmacies were surveyed. Dodoma Region is the capital of Tanzania, with a population of about 2. Dodoma has about 23 private pharmacies and 5 out of the 9 accredited pharmacies were surveyed. Kilimanjaro region has a population of about 1. Kilimanjaro had about 23 private pharmacies and 4 out of 6 accredited private pharmacies were surveyed. The purposeful sampling technique was used to select 33 private pharmacies that have been accredited to provide services to NHIF beneficiaries. Purposeful sampling seeks information-rich cases relevant to the study. The premises were selected from the three districts of Dar es Salaam region i. Ilala, Kinondoni, and Temeke, and from one district in each of the other three surveyed regions. Pharmacies that were located near the Regional or District Hospitals were chosen. The public hospitals usually experience frequent stock-out, hence we expected many patients would seek medicines in the nearby private pharmacies. We ensured that the selected essential medicines were also on the NHIF reimbursement list. Data were collected on the same dosage form and strength for each medicine. Data collection tools were piloted at Kibaha District Council in the Coast region, which was chosen because of its proximity to Dar es Salaam and the presence of Tumbi regional hospital that is surrounded by NHIF-accredited private pharmacies. Only the tracer medicines that were available in more than ten pharmacies were included in the analysis. Figure 2 shows the mean pharmacy prices of 9 antipyretic medicines in the four regions and the NHIF reference price. Figure 3 shows the mean private pharmacy prices for medicines used in the management of cardiovascular diseases across the four regions and NHIF reference prices. We observed more variation in pharmacy prices for relatively more expensive medicines than cheap ones. Figure 4 shows the mean pharmacy prices of 7 medicines used for the management of diabetes in the study regions and the NHIF reference prices. The study indicates that there is a large variation in prices of surveyed essential medicines sold in private pharmacies in the sampled four regions in Tanzania. The study has also shown that nearly half of the sampled medicines in the private sector pharmacies are sold at a price that is higher than the reference prices used for reimbursement by the National Health Insurance Fund NHIF. Anecdotal evidence shows that when patients covered by NHIF visit accredited private pharmacies to fill their prescriptions, they are denied access to the prescribed essential medicines if the reference price is lower than the price in the pharmacy, otherwise they have to co-pay from their pockets the price difference. Therefore, our finding of the large price differences between the pharmacies and NHIF may suggest that insured patients are at risk of being denied access to the prescribed medicines or face high out-of-pocket co-payments. They are also the preferred source of medicines for many reasons including frequent stock-out in the public facilities, easy geographical accessibility, shorter waiting times, long opening hours \\\\\\\\\\\\\[ 27 , 28 \\\\\\\\\\\\\]. These premises will continue to be an important source of medicines to patients in these countries in the foreseeable future as the public sector where the poor rely on affordable health care continue to suffer from poor quality of care often characterized by frequent stock-out of essential medicines. Unfortunately, evidence has shown that prices in the private sector are 9—20 times higher than the international reference prices for lowest-priced generics \\\\\\\\\\\\\[ 29 \\\\\\\\\\\\\]. Therefore, it is important to establish a regulatory mechanism in countries such as Tanzania where such systems are nonexistent to ensure prices of essential medicines are closely monitored and controlled to enhance progress to Universal Health Coverage and Sustainable Development Goals. In the absence of such policies and regulations, the emerging and expanding health insurance schemes will also suffer \\\\\\\\\\\\\[ 30 \\\\\\\\\\\\\]. Such a rigorous system will enhance access to essential medicines and minimize fraudulent co-payments in the private sector. Evidence from Mali shows that the government was able to correct market imperfection by introducing regulation on medicine pricing, which led to an overall price reduction and improved access to essential medicines in the private pharmacy \\\\\\\\\\\\\[ 31 \\\\\\\\\\\\\]. However, ever since the domestic production of pharmaceuticals has decreased significantly to be replaced with importation. More than half of the imported medicines in Tanzania in terms of market value comes from Indian Pharmaceutical companies followed by Egypt. Antibacterial, analgesics, and antimalarial medicines were the top three categories \\\\\\\\\\\\\[ 34 \\\\\\\\\\\\\]. The inability of local industries to produce enough low-cost generics medicines satisfying Good Manufacturing Practice standards \\\\\\\\\\\\\[ 33 \\\\\\\\\\\\\], means imports from external sources will continue to dominate the Tanzanian market. A study by Ewen et al. Lack of effective pricing policies and regulations means prices in the private sector pharmacies will remain higher than international prices, making treatments for chronic conditions such as diabetes and cardiovascular diseases unaffordable to many in low- and middle-income countries \\\\\\\\\\\\\[ 29 \\\\\\\\\\\\\]. Health Technology Assessment methodology, which provides a systematic way of informing pricing and reimbursement decisions in most high-income countries is relatively a new concept in the developing world \\\\\\\\\\\\\[ 36 \\\\\\\\\\\\\]. Tanzania also does not have an agency devoted to controlling medicine prices, although it does have one for controlling prices of energy and water utilities \\\\\\\\\\\\\[ 37 \\\\\\\\\\\\\]. In the absence of such systems, market forces may be the only factor that determines the prices of medicines in the private sector. However, as this study and others have pointed out, market forces alone may not be sufficient to ensure the efficient and equitable distribution of healthcare services, which necessitates government intervention \\\\\\\\\\\\\[ 38 \\\\\\\\\\\\\]. The NHIF determines the reimbursement rates based on market surveys on the prevailing prices and actuarial evaluations \\\\\\\\\\\\\[ 22 \\\\\\\\\\\\\]. Apart from this, there is no clear information on how they arrive at the final reimbursement prices of medicines. This underscores the importance of establishing a more transparent and effective pricing system considering that prices in the dominant private market are highly inflated compared to the corresponding international price \\\\\\\\\\\\\[ 29 \\\\\\\\\\\\\]. Medine prices are also prone to currency fluctuations, and as this study shows vary a lot between regions. Another challenge was that the NHIF reference price list used during the study period was updated more than 3 years ago, which could explain why prices for some medicines were in most cases lower than the prices we found in the private pharmacies. Through the interviews with owners and operators of the pharmacies, we learned that selling medicines at the reference prices would mean incurring losses, which explains why patients were being told to pay the difference or being denied access. Therefore it is important to review the reference price list more frequently through an open and transparent process that engages the key stakeholders. This study has several limitations. First, the sample size was relatively small for medicines surveyed in Morogoro, Dodoma, and Kilimanjaro regions. The reason being the small number of accredited pharmacies in these regions. With a small sample size, one can easily reach a wrong conclusion. However, despite this weakness, the findings of this study highlight an important problem that needs further investigation. Second, we did not have enough data to determine factors that are associated with price variation. Hence, we failed to provide answers as to why the prices of some medicines in Dar es-Salaam region were higher than in other regions. We expected lower pharmacy prices in Dar es-Salaam because of market competition and lower transport costs, because it is an import hub and contains more than half of all pharmacies in the country. Third, we were not able to compare the private pharmacy and the NHIF reimbursement prices to the international reference prices, which could have shed more light on how local retail medicine prices compare to the corresponding international prices. Also, there was a significant difference between the pharmacy and the NHIF reimbursement prices. Often, when the NHIF reimbursement prices are lower than the private pharmacy prices, patients are asked to pay the difference, which may expose them to fraudulent co-payments that further increases their vulnerability to high out-of-pocket payments or it may delay timely access to the prescribed medicines. Non-communicable diseases-Key facts. Geneva: World Health Organization; Google Scholar. Disability-adjusted life years DALYs for diseases and injuries in 21 regions, — a systematic analysis for the global burden of disease study Article Google Scholar. Raising the priority of preventing chronic diseases: a political process. Amuna P, Zotor FB. Epidemiological and nutrition transition in developing countries: impact on human health and development. Proc Nutr Soc. Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, — a systematic analysis for the global burden of disease study Priority actions for the non-communicable disease crisis. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. Progress on catastrophic health spending in countries: a retrospective observational study. Lancet Glob Health. The impact of health insurance in Africa and Asia: a systematic review. Bull World Health Organ. Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review. Int J Equity Health. What factors affect voluntary uptake of community-based health insurance schemes in low- and middle-income countries? A systematic review and meta-analysis. PLoS One. United Nations. Geneva: United Nations; The world medicine situation: medicines prices, availability and affordability. WHO guideline on country pharmaceutical pricing policies. Policies to promote use of generic medicines in low and middle income countries: a review of published literature, Health Policy. Does external reference pricing deliver what it promises? Evidence on its impact at national level. Eur J Health Econ. United Republic of Tanzania. Dar es Salaam. Creating a new class of pharmaceutical services provider for underserved areas: the Tanzania accredited drug dispensing outlet experience. Prog Community Health Partnersh. Accessed 6 July Health Policy Plus. Measuring medicine prices, availability, affordability and price components. Geneva; Ministry of Health and Social Welfare. Dinno A. Stata J. Smith F. Private local pharmacies in low- and middle-income countries: a review of interventions to enhance their role in public health. Tropical Med Int Health. The availability, pricing, and affordability of essential diabetes medicines in 17 low-, middle-, and high-income countries. Front Pharmacol. Understanding the role of accredited drug dispensing outlets in Tanzania's health system. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Health insurance systems in five sub-Saharan African countries: medicine benefits and data for decision making. Assessment of the impact of market regulation in Mali on the price of essential medicines provided through the private sector. The National Medicine Policy. Dar es salaam: Ministry of Health and Social Welfare; Arusha: The East African Community; Pharmaceuticals imports in Tanzania: overview of private sector market size, share, growth and projected trends to Prices and availability of locally produced and imported medicines in Tanzania. The Government of the United Republic of Tanzania. Dar es Salaam; Are market forces strong enough to deliver efficient health care systems? Confidence is waning. Health Aff Project Hope. Download references. We thank the anonymous reviewers for providing constructive comments and suggestions that we have used to improve the draft of the manuscript. Box , Dar es Salaam, Tanzania. Box , , Bergen, Norway. You can also search for this author in PubMed Google Scholar. RK was responsible for data collection, management, and analysis. RK and ATM wrote the first draft of the manuscript. All authors have reviewed and approved the submission of the manuscript. Correspondence to Amani Thomas Mori. Permission to conduct the study in the selected pharmacies was sought from the Tanzania Medicines and Medical Devices Authority. Study participants to be interviewed were asked to provide verbal consent after being guaranteed that no identity revealing information will be recorded in the questionnaire. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Table 1. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Reprints and Permissions. Kirua, R. Prices of medicines for the management of pain, diabetes and cardiovascular diseases in private pharmacies and the national health insurance in Tanzania. Int J Equity Health 19, Download citation. Received : 14 July Accepted : 03 November Published : 10 November Skip to main content. Search all BMC articles Search. Download PDF. Abstract Background High price is a major challenge limiting access to essential medicines especially among the poorest families in developing countries. Results Twenty-eight essential medicines, of which 9 are used for management of pain, 7 for diabetes, and 12 for cardiovascular diseases were analyzed. Conclusion The study found that medicine prices in private pharmacies vary a lot between the study regions, which raises equity concerns. Introduction Over the past two decades, there has been a substantial epidemiological transition of diseases from communicable to non-communicable diseases NCDs. The situation in Tanzania Tanzania is an East African country with more than 45 million people \\\\\\\\\\\\\[ 19 \\\\\\\\\\\\\]. Methodology Study design and context This was a cross-sectional study, which was conducted in four regions of Tanzania, namely Dar es Salaam, which is located in the coastal zone, Morogoro and Dodoma in the central zone, and Kilimanjaro in the northern zone Fig. Study regions. Full size image. Results Medicines for management of pain antipyretics Figure 2 shows the mean pharmacy prices of 9 antipyretic medicines in the four regions and the NHIF reference price. Pharmacy and NHIF reference prices for antipyretic medicines. Pharmacy and NHIF prices for medicines used to manage cardiovascular diseases. Pharmacy prices and NHIF reference price for antidiabetic medicines. Discussion The study indicates that there is a large variation in prices of surveyed essential medicines sold in private pharmacies in the sampled four regions in Tanzania. Study limitations This study has several limitations. References 1. Google Scholar 2. Article Google Scholar 3. Article Google Scholar 4. Article Google Scholar 5. Article Google Scholar 8. Article Google Scholar 9. Article Google Scholar Google Scholar Article Google Scholar Download references. Acknowledgments We thank the anonymous reviewers for providing constructive comments and suggestions that we have used to improve the draft of the manuscript. Funding None. View author publications. Ethics declarations Ethics approval and consent to participate Ethical clearance to conduct the study was sought from Muhimbili University of Health and Allied Sciences Ethical Review Board. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Supplementary Information. Additional file 1: Table 1. Additional file 2: Table 2. Prices Tsh of medicines for management of cardiovascular diseases. Additional file 3: Table 3. About this article. Cite this article Kirua, R. Contact us Submission enquiries: Access here and click Contact Us General enquiries: info biomedcentral.

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