Senegal Assessment

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(No Transcript)
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Senegal Assessment Louis Teulieres
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The purpose of this study is to

• Determine the key elements of access to medicines
  in Senegal
• Estimate the various roles of operators in the
  pharmaceutical sector
• Identify factors on which it would be possible to
  act to improve the situation
• Propose possible actions to be implemented to
  improve access

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Economic and Health/Social Context

• GDP per capita USD 435 in 1999
• Heavy burden of debt limits the volume of public
  financing assigned to social sectors.
• High incidence of poverty, more than 30 of
  households
• Main diseases (public facility consultations)
  malaria (33.2), skin diseases (13), diarrhea
  (8.1), ENT conditions (6.7) and respiratory
  diseases (6)
• Attendance at public facilities is low (30 on
  average), and there are strong regional
  disparities

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Characteristics of the Pharmaceutical Sector

• Most drugs on the market imported
• Local production by two pharmaceutical companies
• most branded products under license
• some generics (branded or International
  Nonproprietary Names INN) -- less than 5 of
  turnover
• Distribution of medicines undertaken by
• private sector (85 of the market, 2,500
  references) three wholesalers and 532 retail
  pharmacies
• public sector five regional warehouses, and at
  base, health care centers with essential
  medicines under INN (350 references) with full
  cost recovery from population
• illicit market supply

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Price of Medicines

• Retail prices of medicines are controlled by the
  Administration. They are calculated (in the two
  licit distribution channels) by applying ad
  valorem margins to the purchase prices, leading
  to high multipliers (1.86 for the private field
  and 1.80 for the public field) and a retail price
  nearly twice as large as the before-tax French
  wholesale price (BTWP).

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Price of Medicines (2)
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Financing of Pharmaceutical Expenditures
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Financing of Pharmaceutical Expenditures (2)
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Method

• Access to medicine is defined as a combination
  of geographic accessibility, the nature and the
  availability of the supply, the ability to pay,
  together with more qualitative factors, such as
  the quality of the prescription, quality of
  drugs, and quality of dispensation.
• Definition of Access
• Environmental factors (geographic access,
  physical availability and financial
  accessibility)
• Effectiveness factors that strengthen or
  attenuate the former ones
• Access Measurement
• A theoretical approach to elaborate measure
  indicators
• A practical approach using two surveys

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Geographical Accessibility

• Median coverage 1 pharmacy per 18,000
• One health post with essential drugs for 7,400
  people
• 78 of the population lives within 5 km of a
  facility with a sustainable stock of
  pharmaceuticals

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Geographical Accessibility (2) Population
Coverage Compared to Poverty
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Availability

• Determined from list of 26 tracer essential drugs
  
• 80 availability in the private sector
• 64 availability in the public sector
• 41 of surveyed patients stated they could not
  buy a whole prescription because of availability
  problems

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Availability (2)
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Financial Accessibility 50 of population
spends less than 3 per year on health. 5 of the
population spends over 35 per year.
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Financial Accessibility (2)
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DS/Health Spending

• National Survey Results
• Median price for drug purchase is 1,000 Fcfa,
  higher than theoretical accessibility for 60 of
  the population
• 24 of patients at public facilities were given a
  second prescription to be filled in a private
  pharmacy where median cost is 2,661 Fcfa, for a
  total cost of 3,661 Fcfa, higher than theoretical
  accessibility for 80
• Comparison of Drug Expenditure with Daily
  Spending (DS)
• In public facilities, cost of recent drug
  purchases is 1.4 times DS (1,591 Fcfa). In
  private pharmacies, costs are 1.6 times DS (4,735
  Fcfa).
• Cost was higher than 1 DS in public facilities
  for 29 of cases, and for 50 of cases in private
  pharmacies
• For 15 of patients at public facilities and 30
  of those at private pharmacies, purchasing costs
  were equal or superior to 3 DS

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DS/Health Spending (2)

• DS of customers at public facilities
• Between 3,401 Fcfa and 5,160 Fcfa
• Corresponds to food expenditures of the 2nd and
  3rd quintiles of households in the DMS 
• DS of customers at private pharmacies
• Between 5,918 Fcfa in 10,341 Fcfa
• Corresponds to 4th and 5th quintiles

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DS/Health Spending (3)

• Two Lessons
• The 20 poorest population (1st quintile) seem to
  be excluded from the system
• A clear cut difference exists between the two
  sets of populations

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Quality of Products and Services

• Average number of lines on a prescription
• 2.8 in the public sector
• 2.6 in the private sector
• Essential drugs on prescriptions
• 44 in the private sector (9 as INN, 91 as
  brands)
• 72 in the public sector (47 as INN)
• Irrational combination of two products of same
  class
• 35 in the public sector
• 26 in the private sector

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Quality of Products and Services (2)

• 19 of public sector patients receive a second
  prescription to be bought in a private pharmacy
• Substitution in 52 of cases, for a more
  expensive product (private sector)
• Dispensation only 22 of patients know what the
  drugs are for, while 40 know how long they
  should be taken

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Quality of Products and Services (3)
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Patients Behavior and Opinion

• 36 patients buy prescription drugs without a
  prescription
• 35 patients use traditional medicines (37 with
  no education, 30 primary education, 26
  secondary education)
• 26 use the illegal market (64 because drugs are
  cheaper, 27 because prescription not needed, 17
  because of location)
• Satisfaction 93 in the private sector, 82 in
  the public sector

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Conclusions

• Drug access in Senegal is low
• Price setting mechanisms, based on proportional
  markups, end up greatly multiplying pre-tax
  wholesale price
• In the public sector, unauthorized price
  increases lead to prices sometimes as high as
  private sector
• Prescription and dispensation practices
  contribute to the situation

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Conclusions (2)

• Dispensation practices often not satisfactory in
  private sector
• Behaviors can be attributed to several factors
• Payment system based on proportional markups
• Unchecked commercial promotion of manufacturers
  target private sector doctors and prescribers in
  public sector facilities
• Markups and promotion largely responsible for
  partial failure of essential drug policy based on
  generics
• Illicit Market Appeal for a significant part of
  population, role keeps growing, consequences on
  treatment duration and observance