Table 1
Median price ratios (MPR) and affordability of generic essential medicines in Nepal.
| Generic name, dosage form, strength | 2015 MSH IRPs (USD) | Public Sector | Private Sector | % price increase in private sector compared to public sector | |||
|---|---|---|---|---|---|---|---|
| MPR (Ratio of Median consumer price to MSH IRP)├ | Number of days’ wages for monthly supply | MPR (Ratio of Median consumer price to MSH IRP)├ | Number of days’ wages for monthly supply | ||||
| 1 | Amlodipine, 5 mg tab | 0.0061 | 6.38* | 0.57 | 7.47* | 0.67 | 17.3% |
| 2 | Aspirin, 100 mg tab | 0.0062 | 0.72 | 0.07 | 0.77 | 0.07 | 7.5% |
| 3 | Atenolol, 50 mg tab | 0.0059 | 5.49* | 0.71 | 6.11* | 0.80 | 11.4% |
| 4 | Atorvastatin, 10 mg/20 mg tab | 0.0233 | 3.14 | 1.08§ | 2.63 | 0.90 | –16.3% |
| 5 | Benzathine-benzylpenicilline, 2.4 million IU | 0.2254 | N/A | N/A | 0.79 | 3.97§ | 4.7% |
| 6 | Captopril, 25 mg tab | 0.0076 | N/A | N/A | N/A | N/A | N/A |
| 7 | Digoxin, 0.25 mg tab | 0.0169 | 1.42 | 0.35 | 1.33 | 0.33 | –6.0% |
| 8 | Enalapril, 5 mg | 0.0062 | 4.64* | 0.85 | 6.08* | 1.11§ | 31.0% |
| 9 | Frusemide, 40 mg tab | 0.0062 | 1.24 | 0.11 | 1.37 | 0.13 | 10.5% |
| 10 | Glibenclamide, 5 mg tab | 0.0053 | 14.79* | 2.31§ | N/A | N/A | N/A |
| 11 | Gliclazide, 80 mg tab | 0.0222 | 1.98 | 1.30§ | 2.79 | 1.83§ | 41.5% |
| 12 | Hydrochlorothiazide, 25 mg tab | 0.0049 | 5.43* | 0.39 | 5.09* | 0.37 | –6.3% |
| 13 | Isosorbide Dinitrate, 10 mg tab | 0.0215 | N/A | N/A | 0.94 | 1.78§ | N/A |
| 14 | Losartan, 50 mg tab | 0.0181 | 3.01 | 0.80 | 3.83 | 1.02§ | 27.2% |
| 15 | Metformin, 500 mg tab | 0.0162 | 0.89 | 0.85 | 1.18 | 1.13§ | 33.3% |
| 16 | Nifedipine Retard, 20 mg tab | 0.3840 | 0.11 | 0.90 | 0.13 | 1.06§ | 17.8% |
| 17 | Propranalol, 40 mg tab | 0.0108 | 2.42 | 1.54§ | 3.55 | 2.26§ | 47.1% |
| 18 | Ramipril, 5 mg tab | N/A | N/A | 0.69 | N/A | 0.80 | 16.5% |
| 19 | Simvastatin, 20 mg tab | 0.0163 | N/A | N/A | N/A | N/A | N/A |
| 20 | Soluble insulin, 40 IU vial | 4.3800 | 0.47 | 3.02§ | 0.49 | 3.18§ | 5.2% |
| 21 | Spironolactone, 25 mg tab | 0.0442 | 0.72 | 1.40§ | 0.66 | 1.30§ | –7.3% |
| Median MPR [range] | 2.19 [0.11–14.79] | 1.37 [0.13–7.47] | Mean: 13.8% | ||||
| Mean (SD) [Median (range)] number of daily wages for monthly supply | 1.03 (0.77) [0.85 (0.07–3.02)] | 1.26 (1.03)[1.04 (0.07–3.97)] | |||||
[i] ├ Median Price Ratio (MPR) is calculated by dividing the median consumer price of a given medicine with the respective MSH international reference price (IRP). An MPR of 1.00 would mean that the medicine consumer price is equal to its IRP. The WHO recommends that median consumer price should not be 4 times greater than the MSH IRP. MRPs greater than 4.00 are marked with asterisks (*).
All unaffordable medicines (i.e. those medicines for which a month’s supply costs > 1 day’s lowest paid wage) are marked with symbol (§). N/A refers to the medicines where MSH IRP or at least four consumer price data points were not available.
Table 2
Availability, prices and affordability of routine CVD and diabetes diagnostic tests in secondary and tertiary healthcare facilities in Nepal.
| Name of the diagnostics | Availability (%) | Median Price of single test (USD) | No. of day’s wages for a single test | ||||
|---|---|---|---|---|---|---|---|
| Public Sector (N = 9) | Private Sector(N = 3) | Overall | Public Sector | Private Sector | Public Sector | Private Sector | |
| Creatinine | 100.0% | 100.0% | 100.0% | 0.96 | 1.92 | 0.47 | 0.94 |
| ECG | 77.8% | 66.7% | 75.0% | 1.92 | 2.88 | 0.94 | 1.41 |
| Full Blood Count | 88.9% | 100.0% | 91.7% | 1.39 | 1.92 | 0.68 | 0.94 |
| Glycemia | 100.0% | 100.0% | 100.0% | 0.58 | 0.96 | 0.28 | 0.47 |
| HbA1c | 55.6% | 33.3% | 50.0% | 3.84 | 0.96 | 1.88 | 0.47 |
| HDL cholesterol | 55.6% | 66.7% | 58.3% | 1.92 | 1.68 | 0.94 | 0.82 |
| Kalemia | 55.6% | 66.7% | 58.3% | 1.34 | 2.64 | 0.66 | 1.29 |
| LDL Cholesterol | 11.1% | 0.0% | 8.3% | – | – | – | – |
| Proteinurea | 88.9% | 100.0% | 91.7% | 0.34 | 0.96 | 0.16 | 0.47 |
| Total Cholesterol | 66.7% | 66.7% | 66.7% | 1.44 | 1.68 | 0.71 | 0.82 |
| Triglyceride | 55.6% | 66.7% | 58.3% | 0.96 | 1.68 | 0.47 | 0.82 |
| Urea | 100.0% | 100.0% | 100.0% | 0.96 | 1.92 | 0.47 | 0.94 |
| Uric Acid | 88.9% | 100.0% | 91.7% | 0.94 | 1.92 | 0.46 | 0.94 |
| Mean | 72.6% | 74.4% | 73.1% | 0.68 days | 0.86 days | ||
Figure 1
(A) Mean availability of CVD and diabetes essential medicines in Nepal’s public and private sectors, and (B) Availability and affordability of selected medicines in the private-sector facilities.
Table 3
Estimated costs of managing cardiovascular risk profile in Nepal’s private and public sectors.
| 3A. Private sector | ||||||||
|---|---|---|---|---|---|---|---|---|
| Prevention | Risk | Intervention | Cost of medicines (USD | no. of days’ wages) | Cost of tests(USD | no. of days’ wages) | Total cost (USD | no. of days’ wages) | Total cost as proportion of monthly household income | ||
| ≤USD 100 | USD 100– ≤200 | USD 200– ≤300 | ||||||
| Primary | <10% | Lifestyle changes + risk monitoring once in 12 months | N/A | 0.571 | 0.28 | 0.571 | 0.28 | 0.57% | 0.29% | 0.19% |
| 10–20% | Lifestyle changes + risk monitoring once in 6 months | N/A | 1.162 | 0.57 | 1.162 | 0.57 | 1.16% | 0.58% | 0.39% | |
| 20–30% | Statina + one antihypertensiveb + risk monitoring once in 6 months | 2.590–4.098 | 1.27–2.01 | 1.162 | 0.57 | 3.752–5.260 | 1.84–2.58 | 3.75–5.26% | 1.88–2.63% | 1.25–1.75% | |
| ≥30% | Statina + one antihypertensiveb + aspirin + risk monitoring once in 3 months | 2.732–4.241 | 1.34–2.08 | 2.304 | 1.13 | 5.036–6.545 | 2.47–3.21 | 5.04–6.55% | 2.52–3.27% | 1.68–2.18% | |
| Secondary | ß-blockerc + ACE Inhibitord + statin a + aspirin + risk monitoring once in 3 months | 5.240–8.849 | 2.57–4.34 | 2.304 |1.13 | 7.544–11.153 | 3.70–5.47 | 7.54–11.15% | 3.77–5.58% | 2.51–3.72% | |
| 3B. Public sector | ||||||||
| Primary | <10% | Lifestyle changes + risk monitoring once in 12 months | N/A | 0.428 | 0.21 | 0.428 | 0.21 | 0.43% | 0.21% | 0.14% |
| 10–20% | Lifestyle changes + risk monitoring once in 6 months | N/A | 0.877 | 0.43 | 0.877 | 0.43 | 0.88% | 0.44% | 0.29% | |
| 20–30% | Statina + one antihypertensiveb + risk monitoring once in 6 months | 2.997–4.037 | 1.47–1.98 | 0.877 | 0.43 | 3.874–4.914 | 1.90–2.41 | 3.87–4.91% | 1.94–2.46% | 1.29–1.64% | |
| ≥30% | Statina + one antihypertensive b + aspirin + risk monitoring once in 3 months | 3.140–4.180 | 1.54–2.05 | 1.733 | 0.85 | 4.873–5.913 | 2.39–2.90 | 4.87–5.91% | 2.44–2.96% | 1.62–1.97% | |
| Secondary | ß-blockerc + ACE Inhibitord + statina + aspirin + risk monitoring once in 3 months | 5.199–7.218 | 2.55–3.54 | 1.733 | 0.85 | 6.932–8.950 | 3.40–4.39 | 6.93–8.95% | 3.47–4.48% | 2.31–2.98% | |
[i] Minimal WHO Recommended tests (fasting blood sugar, cholesterol, potassium levels, proteinuria and ECG) would cost the lowest paid worker 6.10 and 4.16 days’ wages in the private and public sectors respectively. Risk monitoring (lipid profile, fasting blood sugar and proteinuria) would cost 3.40 and 2.56 days’ wages in private and public sectors respectively. From these values, we calculated costs for monitoring risk once in 12 months, 6 months and 3 months.
a Includes atorvastatin and simvastatin; b Includes amlodipine, nifedipine, hydrochlorothiazide, ramipril, captopril and enalapril; c Includes atenolol and propranolol; d Includes ramipril, captopril and enalapril.
Lowest daily wage for workers in Nepal at the time of survey was USD 2.039 (NPR 212.5). Mean household income among the exit interview participants was USD 239.87 (NPR 25,000). Diabetic patients would require a hypoglycaemic medicine (metformin/insulin) which additionally costs 1.13–3.18 days’ wages in private sector and 0.85–3.02 days’ wages in public sector.
Table 4
Medicine accessibility among CVD and diabetes patients.
| Access measures | Number of patients (%) | ||
|---|---|---|---|
| Patients who were diagnosed with and/or prescribed medications for CVD or diabetes (cardio-metabolic). | 636 (100.0%) | ||
| Patients who already had been prescribed with anti-hypertensive medication. | 531 (83.5%) | ||
| Healthcare checkup and consultation by sector, n (%) | |||
| Distribution of healthcare facility-mix where patients sought regular consultations and advice. | |||
| Public sector | 106 (16.7%) | ||
| Private sector | 205 (32.2%) | ||
| Both | 328 (51.1%) | ||
| Patients who missed a scheduled healthcare visit in last one month. | 44 (6.9%) | ||
| Medication use and access, n (%) | |||
| Patients who were diagnosed with and/or prescribed medications for CVD or diabetes (cardio-metabolic). | 636 (100.0%) | ||
| Outlets where patients usually obtained their medications. | |||
| Public-sector hospitals | 115 (18.1%) | ||
| Public-sector primary health care centers | 54 (8.5%) | ||
| Private-sector hospitals/clinics | 361 (56.8%) | ||
| Private retail pharmacies | 106 (16.7%) | ||
| Patients who did not have prescribed cardio-metabolic medications at home, n (%). | 29 (4.6%) | ||
| Reasons reported for limited access (i.e. no medicines at home). | |||
| Medicines unavailable at pharmacy facility. | 1 (3.5%) | ||
| Medicine available but not affordable. | 24 (82.8%) | ||
| Lack of time to purchase medicines. | 4 (13.8%) | ||
| Travel to healthcare/pharmacy facility to obtain medications. | n (% patients) | Time in minutes, Median (IQR) | Cost in NPR, Median (IQR) |
| Mode of Transportation. | |||
| Walk | 342 (53.9%) | 15 (10, 30) | – |
| Cycle | 16 (2.5%) | 20 (10, 30) | – |
| Motor vehicle (Bus/car/taxi) | 276 (9.5%) | 60 (30, 60) | 100 (40, 150) |
| Patients who also use alternative therapy, apart from physician/allopathic treatment, n (%). | 165 (25.9%) | ||
| Ayurveda | 23 (3.6%) | ||
| Homeopathy | 15 (2.4%) | ||
| Salam healers/dhami/Jhakri | 3 (0.5%) | ||
| Home remedies | 109 (17.1%) | ||
| Others | 15 (2.4%) | ||
| Medication adherence | |||
| Morisky predictive score*, Mean (SD) | 2.9 (0.46) | ||
| Patients who ever forget to take medicine on time, n (%) | 71 (11.2%) | ||
| Patients who reported to be careless about taking medicines, n (%) | 604 (95.4%) | ||
| Patients who sometime stop taking medicines when they feel better, n (%) | 30 (4.7%) | ||
| Patients who sometime stop taking medicines when they feel worse, n (%) | 17 (2.7%) | ||
[i] * Adherence level on a scale of 0–4, where score 0 refers to lowest and score 4 refers to highest level of adherence.