Abstract
Purpose
Affordable access to quality medicines is a critical target of global efforts to achieve universal health coverage. The aim of this study is to measure the affordability and accessibility of cardiovascular medicines in the city of Herat, Afghanistan.
Methods
The price, affordability, and availability data for 18 most sold generic (MSG) and lowest priced generic (LPG) products were collected from public and private pharmacies located in Herat city in Afghanistan in 2020, which in each area, six pharmacies were randomly selected from a combination of public and private ones based on the standardized methodology developed by WHO/HAI. According to this methodology on Medicine Prices, Accessibility, and Affordability, the minimum daily wage of an unskilled governmental worker, and the price of each type of cardiovascular medicines for one-month use were calculated separately. If the cost of the treatment was more than the minimum daily wage, the medicine was considered unaffordable.
Results
The mean availability score for lowest price generic (LPG) in public and private pharmacies and based on the countries of origin including Iran, Pakistan, and India was 60%, 46%, and 31%, respectively. Of the 18 medicines surveyed, just Atenolol (Iranian brand) was found in all 30 pharmacies on the day of data collection. All Indian- brand medicines were less than fifty percent available in any of the surveyed public and private pharmacies. Among the medicines exported to Afghanistan, the population of Herat used more medicines made by Pakistan compared to India and Iran (MSG). Indian medicines were the most expensive ones and the Iranian medicines were the cheapest. A wage of less than one day was enough to afford one-month supply of generic medicines at the lowest price.
Conclusion
Access of patients to cardiovascular medicines in Afghanistan was 46% in this study which is regarded as low access. Most of available cardiovascular medicines in the market of this country were made in Iran, Pakistan and India. Although the Iranian ones were the cheapest, but people used more Pakistani medicines. LPG products were affordable to the studied population.
Keywords: Afghanistan, Availability, Affordability, Cardiovascular medicine
Introduction
Affordable access to quality medicines is a critical target of global efforts to achieve universal health coverage [1]. Medicines play a vital role in healthcare, and accessibility is a part of the fundamental human right to health [2, 3]. However, almost a third of the world's population do not afford their medications, mostly because of price barriers [3, 4]. 90% of population living in low- and middle-income countries have to pay for their medicines out-of-pocket (OOP) [4], while 20 to 60 percent of healthcare expenditure is related to medicines [5]. According to WHO guideline, health policy-makers should reconsider their strategies on pricing medicine in order to improve their availability, accessibility, and affordability in Low and Middle-Income Countries (LMICs) [1].
Cardiovascular diseases (CVDs) are the leading causes of death worldwide. An estimated 17.9 million people died from CVDs in 2019, and out of the 17 million premature deaths (under the age of 70) were caused by CVDs [6], Accounting for 44% of all non-communicable deaths (NCDs) and 31% of all causes of death [7], cardiovascular diseases impose considerable economic burden to countries' healthcare systems [8]. Over three quarters of CVD deaths take place in low- and middle-income countries. If cardiovascular medicines are available and affordable, a significant number of diseases and mortality can be prevented [9].
According to the estimation of the Institute of Health Metrics and Evaluation (IHME), the mortality rate of cardiovascular diseases in Afghanistan is 162 (129–196) per 100,000 [10]. There is little data about patients’ access to affordable medicines for the treatment of cardiovascular diseases in low- and middle-income countries [11, 12] but none of them addresses the affordability, availability, and accessibility of cardiovascular medicines in Afghanistan.
Afghanistan is located in the Middle East and the current population of this country is about 40,4 million based on the latest projections of United Nations. According to the WHO report of 2019, the share of total health expenditures in the country's Gross Domestic Product (GDP) was about 9.5%. Afghanistan’s government pays 5.1% of total expenditure on health, whereas, 75.5% is covered by private contributors and 19.4% by donors. Almost 80% of the population is covered by insurance or public health services. Total pharmaceutical expenditure was $872 million in 2017 that made up about 34% of the total health expenditure. All public health services are free of charge but people pay almost all the expenses in private health sector [13].
It seems that the barriers to people's access to pharmaceuticals and their ability to pay for health services, especially for pharmacotherapy and cardiovascular medicines are serious challenges in this country. Therefore, the aim of this study is to measure the affordability and accessibility of cardiovascular medicines in the city of Herat, Afghanistan.
Methods
Study design
This study seeks to generate reliable information on the price, accessibility, and affordability of cardiovascular medicines in the city of Herat, Afghanistan in 2020. Herat is the third-largest city of Afghanistan. In 2020, it had an estimated population of 574,276; and serves as the capital of Herat Province. The study is based on the method developed by WHO and Health Action International (HAI) [14], which has been used in several studies in the different countries [15–18]. A systematic survey was conducted by WHO and HAI to collect data on pricing, accessibility and, affordability of main cardiovascular medicines in 2014, and to provide a policy guidance to address and resolve related problems. According to this method, each country can choose a complementary list of medicines for the treatment of major national health problems. The model has three parts: pricing, affordability and availability.
In this study, the price is expressed as per unit that can be doses or tablet. The retail prices were collected in public and private sectors. The medicines’ prices were transformed into units and recorded on the day of data collection. Only registered products were included in the survey. Price data was obtained by using recent orders from pharmacies. A medicine is considered affordable if it can be purchased at prices that do not distress the finance of households. According to the WHO/HAI methodology on Medicine Prices, Accessibility, and Affordability, the minimum daily wage of a worker, and the price of one-month use of each type of cardiovascular medicines were calculated separately. If the cost of the treatment was more than the minimum daily wage of a worker, the medicine was considered unaffordable.
To evaluate the availability of medicines, all the outlets were surveyed and expressed as the percentage in public and private sectors on the day of data collection. Based on this methodology, the availability of less than 30% is considered very low, 30–49%, low, 50–80%, fairly high, and more than 80% high [14].
Data collection and analysis
In this study, the price, availability and accessibility of 18 most sold generic (MSG) and lowest priced generic (LPG) products including Spironolactone, Atenolol, Clopidogrel, Amlodipine, Telmisartan, Propranolol, Metoprolol, Captopril, Digoxin, Furosemide, Nitroglycerin, Acetyl Salicylic Acid, Atorvastatin, Nifedipine, Telmisartan/Amlodipine, Amiloride/Hydrochlorothiazide, Amiloride, and Trimetazidine were recorded. Despite the longer list of cardiovascular medicines, there were no more products from this group of medicines in the list of Afghanistan’s pharmaceuticals. In all calculations, a fixed dosage for each medicine was considered. To have a better insight about comparative price of cardiovascular medicines in Afghanistan versus other markets, we also searched prices in a few countries with low-price medicines including Iran, Greece, South Africa and Hungary from their governmental sources.
To calculate the sample size, the areas of Herat city were divided into five districts including North, South, West, East and the Center. Then, in each area, six pharmacies were randomly selected from a combination of public and private ones. Moreover, at least, one public sector pharmacy was selected from each area. A total of 30 pharmacies were designated for the study and the access to cardiovascular medicines for the population in the area of each pharmacy was calculated.
Four educated investigators collected necessary data over one month. They checked medicine outlets and collected data using a standard data collection form. For each studied medicine, the data was gathered for most sold generic (MSG) and lowest priced generic (LPG) at every pharmacy. To analyze the data, descriptive statistics including frequency, percentage, mean and standard deviation were considered and One Way ANOVA test was applied.
Results
This study investigates the availability, affordability and pricing of CVDs medicines in the city of Herat Afghanistan in 2020. The results are as following:
Availability
The results of the study on the availability of cardiovascular medicines in public and private pharmacies of Herat, based on thee manufacturing country showed that the most available ones to the population were Iranian, Pakistani and Indian brands (atenolol, propranolol, and trimetazidine) respectively. Iranian-made medicines had the biggest share. The mean availability score for LPG in public sector pharmacies and private facilities based on the producing countries, Iran, Pakistan, and India were 60%, 46%, and 31%, respectively (Table 1).
Table 1.
Availability of different types of cardiovascular medicines in the city of Herat, Afghanistan
| Name of Medicines | Iran | Pakistan | India | Average |
|---|---|---|---|---|
| Spironolactone | 73% | 47% | 27% | 49% |
| Atenolol | 100% | 63% | 30% | 64.3% |
| Clopidogrel | 57% | 57% | 43% | 52.3% |
| Amlodipine | 77% | 57% | 37% | 57% |
| Telmisaetan | 57% | 50% | 37% | 48% |
| Propranolol | 90% | 70% | 20% | 90% |
| Metoprolol | 57% | 53% | 27% | 45.6% |
| Captopril | 73% | 50% | 20% | 47.6% |
| Digoxin | 60% | 50% | 27% | 45.6% |
| Furosemide | 83% | 60% | 40% | 61% |
| Nitroglycerin | 77% | 57% | 37% | 57% |
| Acetyl Salicylic Acid | 73% | 53% | 30% | 52% |
| Atorvastatin | 40% | 43% | 33% | 38.6% |
| Nifedipine | 60% | 33% | 17% | 36.6% |
| Amlodipine + Telmisartan | 20% | 20% | 27% | 22.3% |
| Amiloride + Hydrochlorothiazide | 13% | 23% | 20% | 18.6% |
| Amloride | 17% | 17% | 30% | 21.3% |
| Trimetazidine | 67% | 43% | 47% | 52.3% |
| Avarage | 60% | 46% | 31% | 45.6% |
The pharmaceutical market of Herat is dominated by generics medicines. Of the 18 medicines surveyed, just Atenolol (Iranian brand) was found in all 30 pharmacies on the day of data collection. All Indian- brand medicines were less than fifty percent available in any of the surveyed public and private pharmacies (Table 2).
Table 2.
Availability of different types of cardiovascular medicines in the city of Herat, Afghanistan based on the manufacturing country (n = 19 medicines)
| The manufacturing country | Availability percentage | Type of medicine |
|---|---|---|
| Iran | < 50% | Atorvastatin, Telmisartan + Amlodipine, Amiloride + Hydrochlorothiazide, Amloride |
| 50–60% | Clopidogrel, Telmisaetan, Metoprolol, Digoxin, Nifedipine, | |
| 61–80% | Spironolactone, Amlodipine, Captopril, Nitroglycerin, Acetyl Salicylic Acid, Trimetazidine | |
| 81–99% | Propranolol, Furosemide | |
| 100% | Atenolol | |
| Pakistan | < 50% | Spironolactone, Atorvastatin, Nifedipine, Telmisartan + Amlodipine, Amiloride + Hydrochlorothiazide, Amloride, Trimetazidine |
| 50–60% | Clopidogrel, Amlodipine, Telmisaetan, Metoprolol, Captopril, Digoxin, Furosemide, Nitroglycerin, Acetyl Salicylic Acid, | |
| 61–80% | Propranolol, Atenolol | |
| 81–99% | - | |
| 100% | - | |
| India | < 50% | Spironolactone, Atenolol, Clopidogrel, Amlodipine, Telmisaetan, Propranolol, Metoprolol, Captopril, Digoxin, Furosemide, Nitroglycerin, Acetyl Salicylic Acid, Atorvastatin, Nifedipine, Telmisartan + Amlodipine, Amiloride + Hydrochlorothiazide, Amloride, Trimetazidine |
| 50–60% | - | |
| 61–80% | - | |
| 81–99% | - | |
| 100% | - |
With regard to the type of available medicines, the study showed that the least available cardiovascular medicine in the Afghan pharmaceutical market was the combined medicine of Amiloride + Hydrochlorothiazide (Table 3).
Table 3.
Lowest priced generic and most sold generic medicine based on manufacturing country in different areas of Herat, Afghanistan
| Name of medicine | Iran | Pakistan | India | ||||||
|---|---|---|---|---|---|---|---|---|---|
| number | LPG | MSG | number | LPG | MSG | number | LPG | MSG | |
| Spironolactone | 22 | 2 | 7 | 14 | 2 | 28 | 8 | 3.6 | 30 |
| Atenolol | 30 | 1 | 5 | 19 | 1 | 12 | 9 | 2 | 11 |
| Clopidogrel | 17 | 1.7 | 7.5 | 17 | 1.5 | 19 | 13 | 2 | 7.5 |
| Amlodipine | 23 | 2 | 8 | 17 | 3 | 16 | 11 | 3.6 | 14 |
| Telmisaetan | 30 | 0 | 6 | 30 | 0 | 52 | 30 | 0 | 44 |
| Propranolol | 27 | 1.8 | 7 | 22 | 0 | 18 | 6 | 3 | 10 |
| Metoprolol | 17 | 2 | 7 | 16 | 3 | 9 | 9 | 0 | 18 |
| Captopril | 22 | 2.7 | 7.6 | 15 | 6.1 | 27.5 | 6 | 12.1 | 24.2 |
| Digoxin | 19 | 0 | 4.5 | 15 | 1.5 | 5.6 | 9 | 0 | 8 |
| Furosemide | 25 | 1.6 | 18 | 18 | 2 | 20 | 12 | 2 | 27 |
| Nitroglycerin | 23 | 3 | 30 | 17 | 3 | 57 | 11 | 4.5 | 27 |
| Acetyl Salicylic Acid | 22 | 0.7 | 4.9 | 16 | 0.8 | 9 | 9 | 1 | 7 |
| Atorvastatin | 12 | 1 | 4.5 | 13 | 2.2 | 18 | 10 | 1 | 12 |
| Nifedipine | 18 | 4.5 | 18 | 10 | 6 | 24 | 5 | 2.4 | 24 |
| Telmisartan + Amlodipine | 6 | 6 | 7 | 6 | 6 | 34 | 8 | 4 | 34 |
| Amiloride + Hydrochlorothiazide | 4 | 1 | 5.9 | 7 | 3.5 | 20 | 6 | 3.3 | 21 |
| Amloride | 5 | 3.5 | 7 | 5 | 2 | 5.6 | 9 | 3.5 | 10 |
| Trimetazidine | 20 | 1.5 | 7 | 16 | 0 | 22 | 14 | 2.5 | 23 |
Based on spironolactone, the highest average medicine consumption was related to Pakistani brand (9.48 ± 6.55) and the lowest average drug consumption was related to Iranian brand (1.62 ± 4.45) and this difference was statistically significant (p = 0/016). Also, about the combination medicine of Amiloride + Hydrochlorothiazide, the highest average medicine consumption belonged to Indian-made (12.6 ± 8.52) and the lowest medicine consumption to Iranian-made (3.37 ± 2) and this difference was not statistically significant (p = 0.128) (Table 4).
Table 4.
Mean and standard deviation of affordability of cardiovascular medicines consumed in Herat based on the pharmaceutical products of Iran, Pakistan and India and the differences in the study population
| Name of medicine | Iran | Pakistan | India | Test |
|---|---|---|---|---|
| Standard Deviation ± Mean | ||||
| Spironolactone | 1.62 ± 4.45 | 9.48 ± 6.55 | 8.87 ± 8.70 | F = 4.59,p = 0.016 |
| Atenolol | 1.77 ± 0.82 | 5.89 ± 3.94 | 4.41 ± 3.59 | F = 13.98,p < 0.001 |
| Clopidogrel | 3.62 ± 2.30 | 5.99 ± 5.25 | 4.79 ± 2.12 | F = 1.81,p = 0.175 |
| Amlodipine | 4.76 ± 1.80 | 8.54 ± 5.09 | 6.916.93.54 | F = 5.59,p = 0.007 |
| Telmisaetan | 2.63 ± 2.71 | 9.12 ± 13.59 | 10.13 ± 16.97 | F = 3.11,p = 0.050 |
| Propranolol | 2.85 ± 1.47 | 6.23 ± 3.79 | 5.13 ± 2.58 | F = 9.35, p < 0.001 |
| Metoprolol | 4.03 ± 2.02 | 5.59 ± 1.58 | 6.00 ± 4.92 | F = 1.99,p = 0.151 |
| Captopril | 4.65 ± 1.72 | 15.09 ± 7.26 | 17.42 ± 4.94 | F = 29.25, p < 0.001 |
| Digoxin | 2.33 ± 1.12 | 4.11 ± 1.21 | 3.552.23 | F = 6.72,p = 0.003 |
| Furosemide | 4.02 ± 3.41 | 8.00 ± 6.23 | 7.97 ± 6.25 | F = 4.08,p = 0.023 |
| Nitroglycerin | 9.64 ± 8.65 | 16.78 ± 16.54 | 10.42 ± 5.93 | F = 2.04,p = 0.141 |
| Acetyl Salicylic Acid | 1.22 ± 0.84 | 2.01 ± 2.05 | 2.22 ± 2.21 | F = 1.69,p = 0.196 |
| Atorvastatin | 2.39 ± 1.27 | 12.05 ± 4.82 | 6.40 ± 3.97 | F = 21.53, p < 0.001 |
| Nifedipine | 9.17 ± 4.42 | 10.17 ± 5.97 | 9.06 ± 8.68 | F = 0.12,p = 0.891 |
| Telmisartan + Amlodipine | 6.43 ± 0.46 | 14.73 ± 10.53 | 18.17 ± 11.62 | F = 2.74,p = 0.093 |
| Amiloride + Hydrochlorothiazide | 3.37 ± 2.00 | 11.18 ± 6.90 | 12.60 ± 8.52 | F = 2.39,p = 0.128 |
| Amloride | 4.901.52 | 4.72 ± 1.54 | 5.41 ± 2.33 | F = 0.23,p = 0.796 |
| Trimetazidine | 4.80 ± 1.42 | 7.85 ± 4.47 | 7.34 ± 5.26 | F = 2.69,p = 0.078 |
Price and affordability
Among the medicines exported to Afghanistan, the population of Herat used more medicines made by Pakistan compared to India and Iran. Indian medicines were the most expensive ones and the Iranian medicines were the least expensive and more affordable medications (Table 5). Also, the highest price fluctuation was related to Nitroglycerin. LPG and MSG medicines are presented in Table 3. A wage of less than one day was enough to afford one-month supply of generic medicines at the lowest price.
Table 5.
The availability of cardiovascular medicines based on the manufacturing country in the studied drug stores of the city of Herat, Afghanistan
| Generic name | Iran | Pakistan | India |
|---|---|---|---|
| Number of drug stores (percentage) | Number of drug stores (percentage) | Number of drug stores (percentage) | |
| Spironolactone | 30 (100%) | 24(80%) | 29 (96.7%) |
| Atenolol | 30 (100%) | 25 (83.3%) | 28 (93.3%) |
| Clopidogrel | 30 (100%) | 26 (86.7%) | 30 (100%) |
| Amlodipine | 30 (100%) | 22 (73.3%) | 28 (93.3%) |
| Telmisaetan | 30 (100%) | 21 (70%) | 30 (100%) |
| Propranolol | 30 (100%) | 28 (93.3%) | 29 (96.7%) |
| Metoprolol | 30 (100%) | 30 (100%) | 29 (96.7%) |
| Captopril | 30 (100%) | 21 (70%) | 24(80%) |
| Digoxin | 30 (100%) | 30 (100%) | 30 (100%) |
| Furosemide | 29 (96.7%) | 26 (86.7%) | 29 (96.7%) |
| Nitroglycerin | 23 (76.7%) | 19 (63.3%) | 25 (83.3%) |
| Acetyl Salicylic Acid | 30 (100%) | 30 (100%) | 30 (100%) |
| Atorvastatin | 30 (100%) | 20 (66.7%) | 27 (90%) |
| Nifedipine | 23 (76.7%) | 27 (90%) | 29 (96.7%) |
| Telmisartan + Amlodipine | 30 (100%) | 27 (90%) | 24(80%) |
| Amiloride + Hydrochlorothiazide | 30 (100%) | 27 (90%) | 27 (90%) |
| Amloride | 30 (100%) | 30 (100%) | 29 (96.7%) |
| Trimetazidine | 30 (100%) | 22 (73.3%) | 26 (86.7%) |
WHO have recommended that in the affordability and accessibility studies, the researchers use Management Sciences for Health (MSH) reference prices, so in Table 6, a comparison between the price of cardiovascular medicines in Afghanistan and some lowest price countries such as Iran, Greece, South Africa and Hungary are provided. The lowest and highest prices of different brands or generics for each medicine were extracted from official sources, and then, the daily treatment costs were calculated. However, in some cases, the price of medicines in Afghanistan seemed to be significantly higher than Iran as a neighboring country (Furosemide, Nitroglycerine, Metoprolol, and Captopril).
Table 6.
Comparison of the prices of cardiovascular medicines in Afghanistan and four countries
| Name of medicine | Afghanistan MSG | Iran | Greece | Hungary | South Africa |
|---|---|---|---|---|---|
| Spironolactone | 0.091 | 0.133 | 0.273 | 0.3 | 0.273–0.328 |
| Atenolol | 0.065 | 0.12 | 0.136–0.164 | NA | 0.068–0.278 |
| Clopidogrel | 0.098 | 0.43 | 0.164–0.71 | 0.109–0.177 | 0.261–2.59 |
| Amlodipine | 0.104 | 0.099 | 0.46–0.547 | 0.081–0.109 | 0.245–0.627 |
| Telmisaetan | 0.078 | NA | NA | 0.546–1.1 | 0.781–1.234 |
| Propranolol | 0.091 | 0.048 | NA | NA | 0.027–0.062 |
| Metoprolol | 0.091 | 0.04 | NA | 0.082–0.136 | 0.109–0.162 |
| Captopril | 0.099 | 0.056 | NA | 0.123–0.164 | 0.081–0.203 |
| Digoxin | 0.058 | 0.05 | 0.068 | 0.068 | 0.027–0.068 |
| Furosemide | 0.235 | 0.081 | 0.271–0.326 | 0.136–0.169 | 0.039–0.3 |
| Nitroglycerin | 0.392 | 0.25 | NA | NA | 0.163 |
| Acetyl Salicylic Acid | 0.064 | NA | 0.047–0.107 | 0.026–0.039 | 0.104–0.209 |
| Atorvastatin | 0.058 | 0.083 | 0.273–0.814 | 0.082–0.191 | 0.054–0.81 |
| Nifedipine | 0.235 | 0.25 | 0.123–0.196 | 0.082 | 0.203–0.644 |
| Telmisartan + Amlodipine | 0.091 | NA | NA | 1.359–2.117 | 0.732–1.934 |
| Amiloride + Hydrochlorothiazide | 0.077 | NA | NA | NA | NA |
| Amloride | 0.091 | NA | NA | NA | NA |
| Trimetazidine | 0.091 | NA | 0.082–0.109 | 0.082–0.15 | NA |
All prices are in USD (1USD = 76.5 Afghan Afghani), NA: not available
Discussion
As to the best of our knowledge, the present study is the only one that assess the availability, patient prices, and affordability of medicines for cardiovascular medicines in Afghanistan. This study used the WHO/ HAI methodology [19]. The leading finding of the study was that the availability of the selected medicines for the treatment of CVDs (LPGs and MSGs) were relatively low. In general, the population of Herat had 60%, 46% and 31% access to cardiovascular medicines made in Iran, Pakistan, and India respectively. Totally, the population of this city had an average of 46% access to cardiovascular medicines. Furthermore, according to price and treatment costs comparison, in most cases, the price of cardiovascular medicines in Afghanistan was comparable with four assessed countries (Iran, Greece, Hungary and south Africa). In 2015, Farahani et al. [20] conducted a study to investigate the availability and accessibility of cardiovascular medicines to the population living in Tehran which included 21 items of medications. The results of their study showed that more than 80% of the population of Tehran had access to generic cardiovascular medicines. The results of our study in Herat showed that less than half of the population of this city had access to these medicines. Based on the study by WHO, eight of 11 medicines for the treatment of non-communicable diseases were available in public health sector in Afghanistan [21]; our findings regarding cardiovascular drugs are not consistent with this study results.
The study by Mendis et al. showed that the availability of some key CVD medicines such as Hydrochlorothiazide was poor in several countries including Bangladesh, Pakistan and Seri Lanka. Also, this study showed that one month of monotherapy with hydrochlorothiazide was affordable. However, in some cases, the price was 10–25 times more than the international reference [11]. A study by Van Morrick et al. evaluating the pricing, availability, and affordability of cardiovascular medicines in 36 developing countries such as India, Kyrgyzstan, Pakistan, Tajikistan and Uzbekistan showed that the availability of cardiovascular medicines was 57.3% [12], which according to the HAI references, was fairly high [14].
Study findings showed that Iranian made medicines in Afghanistan were the cheapest and more affordable medications compared with medicines manufactured by two other countries (India and Pakistan). Afghanistan does not produce any CVD medicine, and the medicines used by the residents of Herat are mostly imported from neighboring countries such as Iran, Pakistan and India. Due to the lower price of Iranian medicines, the people in Herat found them more affordable compared with two other medicine manufacturing countries. In addition to less financial barrier, geographical proximity of Herat to the border cities of Iran could also be a reason for this trend. The study by Paterson and Karimi showed that Pakistan and Iran provided a large proportion of the pharmaceutical market in Afghanistan. Iranian medicines were generic and significantly cheaper than other alternatives including Irish, Middle Eastern and Indonesian products [22]. The price of imported medicines in Afghanistan varies from one source to the other; and to all medicines, a tax is added which is being reflected in end user price [18]. In recent years, the number of medicines both donated and privately imported has increased significantly in Afghanistan. However, the illegal parallel importation of medicines into the country is widespread. About 80% of medicines sold in private pharmacies are illegally imported from neighboring countries. The lack of control or regulation of pharmaceutical market can be seen in the pricing of medicines as well. However, many types of medicines on the market are of low quality and price, because the market players aim to address the demand of poor population of this country [22]. Furthermore, to ensure the protection of people against catastrophic health costs, and improving the access to medicines, Afghanistan’s government provides medicines with a substantial subsidy in public health facilities. In the public sector, all medicines are free of charge, but this sector provides less than 50% of the needed medicine. Therefore, people have to purchase medicines from private pharmacies out-of-pocket, and this mean that according to the statistics, people in Afghanistan have to pay about $660 million out of $872 million pharmaceutical costs out of pocket [15]. Moreover, the provision of medicines free of charge in the indigent government system, might endanger the sustainability of the health sector. The study by Kokabisaghi showed that providing selected expensive medicines with subsidy has led to irrational use, and increased induced demand in Iran [23].
Furthermore, the results of the study indicated that the population of Herat can afford and pay for cardiovascular medicines made in Iran, India and Pakistan by 97%, 94% and 87%, respectively. Therefore, a wage of less than one day was enough to afford one-month supply of generic medicines at the lowest price from private and public pharmacies in Herat. Zaprutco et al. concluded that in poor countries of Europa (EU) such as Bulgaria, Romania and Latvia, the price of medicines were the same or higher than EU rich countries [4], which could adversely affect people’s affordability to prepare their necessary medicines. The study by Iyengal et al. showed that in the most of the Organisation for Economic Co-operation and Development (OECD) countries, medicine was not affordable [24]. The study of Farahani et al. in Iran showed that the financial ability of the population of Tehran to buy cardiovascular medicines was acceptable [20].
Conclusion
This study showed that the access of patients to cardiovascular medicines in Afghanistan was 46%, which is regarded as low access. Most of available cardiovascular medicines in the market of this country were made by Iran, Pakistan and India. In general, the Iranian made ones were the cheaper, and Indian ones were the most expensive. These medicines seem to be affordable since a wage of less than one day was enough to afford one-month supply of generic medicines at the lowest price.
Acknowledgements
Authors are grateful to all the individuals who contributed to the data gathering of this study.
Funding
This study extracted from a university project (Project code: 981041) and funded by the Mashhad University of Medical Sciences, Iran.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on a reasonable request.
Declarations
Ethics approval
Ethical approval for this study was sought and obtained from the Mashhad University of Medical Sciences, Iran. (No. IR.MUMS.REC.1398.278).
Conflict of interest
The authors declare that they have no conflict of interests.
Footnotes
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Mehdi Varmaghani, Email: varmaghanim@mums.ac.ir.
Javad Moghri, Email: moghrij@mums.ac.ir.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on a reasonable request.