Availability, price and affordability of essential medicines for managing cardiovascular disease in Addis Ababa, Ethiopia

Abstract

Access to health care is a fundamental human right. However, nearly one-third of the global population have no access to it. This magnitude is even much worse in low- and middle-income countries. A cross-sectional study was conducted from April 12 to June 5, 2024 to determine availability, price and affordability of essential medicines for managing cardiovascular diseases using WHO/HAI methodology in Addis Ababa, Ethiopia. Data on the availability and price of the lowest priced generic medicines were collected from five public, ten private and eight other sectors in Addis Ababa, Ethiopia. The availability was assessed as the percentage of health facilities that stocked the listed medicines. The prices of these medicines were evaluated across all sectors. Price variations were calculated to identify differences among these settings. Additionally, medicine prices were compared against the management sciences for health (MSH) International Reference Prices to calculate the Median Price Ratio (MPR), providing a standardized measure of price affordability and accessibility. The data was analyzed using WHO/HAI work book Excel sheet V 15. The overall availability of generic drugs in all sectors was found to be 34.52%. The availability was 33.73, 40.58, 29.8 and 33.99% in Public, Private, Kenema and Red Cross pharmacies, respectively. The median price ratios for the medications used to treat cardiovascular disease were 3.49, 7.24, 2.84 and 5.2 at Public, Private, Kenema, and Red Cross Pharmacies, respectively. Majority of the medicines were found to be unaffordable, costing up to 352.44 days’ wage of the lowest paid government employee to cover a one-month standard treatment. In conclusion, the study underscores significant challenges in the availability, pricing, and affordability of LPG medications to treat CVDs in Ethiopia.

Introduction

Access to healthcare is increasingly recognized as a fundamental human right, grounded in moral and ethical principles that emphasize dignity, equity, and social justice. This perspective is supported by various frameworks, including international human rights law, which obligates states to ensure access to healthcare for all citizens^1,2. However, for this right to be fulfilled, equitable and timely access to essential medicines for priority diseases has to be attained. Essential medicines, as defined by the world health organization (WHO), are those that satisfy the priority healthcare needs of the population. They should be consistently available in adequate amounts, in appropriate dosage forms, of guaranteed quality, and at affordable prices^3,4. The WHO model list of essential medicines (EML) serves as a critical reference for countries to develop their national lists, ensuring that effective, safe, and cost-effective medicines are accessible for priority health conditions⁵. Ensuring adequate access to effective, safe, and quality essential medicines is crucial for meeting healthcare needs globally. The lack of availability and affordability of these medicines significantly hampers health outcomes⁶.

Despite the fact that access to essential medicines is considered a crucial part of the fulfilment of the right to health care, nearly one-third of global population have no adequate access to essential medications, which is even much worse in the poorest countries of Africa and Asia where half of the population lacks such access⁷. Studies indicate significant challenges regarding the availability of essential and non-essential medicines in Africa and low- and middle-income countries (LMICs). The median availability of essential medicines for women and children in sub-Saharan Africa is notably low, with a median of 33% for essential medicines for women and 50% for children⁸. Furthermore, a systematic review of studies from 2009 to 2021 revealed that the median availability of essential medicines across various facilities in Africa was often below acceptable levels, with many countries reporting stockout⁹.

Adequate access to essential medicines is a fundamental aspect of healthcare, ensuring that individuals can obtain necessary medications without financial hardship. This access is characterized by the continuous availability and affordability of essential medicines at health facilities within reasonable proximity to the population¹⁰. United Nation (UN) has defined access to medication as continuously available and affordable at a health facility or medicines outlet, within one hour walk from the patient’s home¹¹.

Weak local manufacturing capabilities, regulatory frameworks, under developed infrastructure, inadequate research and development, and international collaborations are the most common causes of unavailability and unaffordability of essential medicines in undeveloped countries¹².

Cardiovascular diseases (CVDs) are groups of diseases that mainly affect the heart and blood vessels. According to the world health organization (WHO), these disease groups are the leading cause of death globally with more than 75% of these deaths occur in low- and middle-income countries (LMICs). CVDSs are also costly disease of all to manage¹³.

The global burden of cardiovascular diseases (CVDs) is staggering, with CVDs being the leading cause of death worldwide, accounting for approximately 18 million deaths annually and 366 million disability-adjusted life years (DALYs) lost¹⁴. Low- and middle-income countries (LMICs) bear a disproportionate share of this burden, with over 80% of CVD-related deaths occurring in these regions¹⁴. The increasing prevalence of risk factors such as smoking, obesity, and hypertension, alongside limited access to healthcare, exacerbates the situation in LMICs^15,16.

The burden of CVDs in Ethiopia is significant and escalating, contributing to a substantial portion of the overall noncommunicable disease (NCD) burden. CVDs accounted for approximately 42% of deaths in the country, with ischemic heart disease and stroke being the leading causes of mortality among NCDs^17,18.

Medicines play a crucial role in managing cardiovascular diseases (CVDs) by addressing their multifactorial nature and associated risk factors. Pharmacological interventions are essential for reducing morbidity and mortality associated with CVDs, particularly through the modulation of chronic inflammation and risk factor management¹⁹. In patients with CVDs, effective pharmaceutical management is crucial due to the complexities of polypharmacy, long-term disease management, and comorbidities. The integration of tailored treatment strategies is essential to mitigate risks associated with multiple medications, ensuring optimal health outcomes^20,21. This will result in a great need for long-term and multiple medication adherence^22,23. However, in this group of patients, nonadherence to prescribed treatment remains a significant barrier to improved patient outcomes. The availability and cost of medications are considered the major factors contributing for the high rate of non-adherence²³.

WHO, health action international (HAI) and a group of international experts drafted a methodology and survey framework to measure medicine prices, availability, affordability and price components to overcome the difficulty in finding reliable information on medicine prices and availability which will assist the policymakers and as well as the governments in constructing sound medicine pricing policies or evaluating their impact to improving access to essential medications for universal health coverage¹.

The availability and cost of medications are the most critical factors for providing healthcare users with quality healthcare and are the most pressing concerns for patients and healthcare systems globally. In many settings, access to medicines in the public sector is poor, and, even though medicines are more available in the private sector, they are often much more expensive, leading to high out-of-pocket expenses that are a burden for patients and their families, thereby limiting access to care¹.

Despite the prevalence and death from CVDs are known to be increasing in Ethiopia⁸, access to medications for those disease treatment is not adequately evaluated. The aim of this study was to evaluate the availability, price, and affordability of essential medicines for managing CVDs in Addis Ababa, Ethiopia. This study could be source of reliable data for policy and strategy development that can be used to improve access to essential medicines for CVDs as well as an input for researches that will be done in the future.

Methods

Study settings

Addis Ababa is capital city of Ethiopia, with a estimated population size of 3,384,569 with an area of 540 square Kilometers. The city comprises 11 sub cities and 116 districts. The city consists of a total of 13 public hospitals with seven hospitals owned by Addis Ababa administration health bureau and six hospitals owned by Federal Ministry of Health (FMoH). There are around 386 private community pharmacies; 42 Kenema Public community pharmacies, and three Red Cross pharmacies in the Addis Ababa city.

For this study five public hospitals of which two owned by the FMoH (i.e. Tikur Abessa Specialized Hospital and Eka Kotebe General Hospital) and the other three owned by Addis Ababa city administration (Zewditu Memorial Hospital, Yekatit 12 Hospital, and Menelik II Comprehensive Specialized Hospital) were selected conveniently to have proportionate coverage for both FMOH and Addis Ababa City Administration Health Bureau. In addition, these hospitals are known to provide diverse service for the highest number of the population. Ten private community pharmacies found around those hospitals and eight other sectors pharmacies (3 Red Cross and 5 Kenema Public Community Pharmacies) were included in the study. Kenema pharmacies are community pharmacies managed by Addis Ababa City Administration Health Bureau. These pharmacies were first founded during socialist era in the 1970’s. These pharmacies served as an additional source of medicines for the public., They have different structure and management from the public pharmacies., Hence, we considered as other sector pharmacies.

Study design and period

A cross-sectional study was conducted from April 12 to June 5, 2024 to determine availability, price and affordability of essential medicines for managing CVDs using WHO/HAI methodology modified for this purpose.

Source population

All public hospitals, private retail pharmacies and other sector pharmacies (Kenema and Red Cross Pharmacies) were the source population for this study. Among them five public hospitals, ten private community pharmacies and eight other sectors (three Red Cross and five Kenema pharmacies) were selected for sample population.

Sample size and sampling methods

According to WHO/HAI standardized sampling methodology to assess availability, price and affordability of medicine for one region in a country, five public hospital outpatient pharmacies are needed at minimum and these hospitals serves to anchors the other sectors (private community pharmacies, Red Cross Pharmacies and Kenema Public Pharmacies) which are chosen randomly according to their proximity to the public hospitals¹.

In this study the five public hospitals were chosen according to the variety of their specialty area coverage and the number of population they serve per year. Two private community pharmacies found around each public hospital was selected randomly after all private retail pharmacies around those hospitals were listed. For the other sectors (Red Cross and Kenema public pharmacies) drug outlets were chosen according to their proximity to the selected public hospitals. From the three Red Cross Pharmacies found in the city, two were selected. There were around 42 Kenema Public Community Pharmacies which are far apart in the city, from them five were selected conveniently based on proximity to the selected hospitals. In total eight other sectors were included (3 Red Cross and 5 Kenema public pharmacies). A total of 23 pharmacies outlets were included in this study.

The essential drugs for this study were all the 40 medicines included in category of CVS medicines from recent essential medicine list (EML) of Ethiopia.

Data collection process and analysis

Data collection process was undertaken by two graduating pharmacy students by visiting the pharmacy outlet. They recorded medicines found on the day of visit and their prices. A standardized data collection questionnaire was developed after necessary modifications of WHO/HAI methodology workbook part I for measuring medicine price, availability, and affordability. The WHO/HAI methodology has undergone significant updates since its inception to enhance the measurement of medicine prices, availability, and affordability. Initially developed in response to a 2001 World Health Assembly resolution, the methodology has evolved through field testing and practical experience, leading to the publication of updated manuals in 2008 and subsequent years. The methodology now includes comprehensive steps for conducting surveys on medicine prices and availability, ensuring consistency across different regions²⁴. Recent surveys have validated the methodology’s effectiveness in various contexts, including urban settings in India and the USA, demonstrating its adaptability. The methodology emphasizes the collection of data on both originator brands and generic medicines, allowing for comparative analysis against IRPs^25,26. Hence, the study was conducted to examine the pricing, availability, affordability, and access to CVDs medicines in Ethiopia, using an abridged WHO/HAI methodology updated in July 2020¹, and this version was effectively utilized in recent studies conducted in Ghana²⁷.

The data regarding the price of medications was taken from the price list of the medicine in the selected health facilities. For each medicine in the survey, data was collected for the lowest priced generic (LPG) medicine found at each medicine outlet. Among the different generics of the same medicine, LGP medicine for the patient was selected for this study. The term LPG refers to a pricing strategy where a retailer guarantees the lowest price for a generic product, often matching or beating any lower price found in the market. This concept is closely related to low price guarantees in retail, which serve as a signal to consumers about price commitment and can influence purchasing behavior. LPGs are designed to enhance consumer trust and reduce price comparison efforts, thereby potentially increasing sales for retailers^28,29. It was known that there is no originator brand of the medicines in the country during the assessment, this was also verified during the data collection.

The study was conducted to examine the pricing, availability, affordability, and access to CVDs medicines in Ethiopia, using an abridged WHO/HAI methodology.

Data analysis was conducted using WHO/HAI methodology workbook part II for measuring medicine price, availability, and affordability.

Based on WHO/HAI methodology the availability of each survey medicines was evaluated by assessing the presence of the LPG medicine in each pharmacy outlet on the day of data collection. Availability for individual medicine was calculated as outlets with the medication divided by the number of the outlets included³⁰. Then mean percent (%) availability of all medications in each type of pharmacy outlets and finally the overall availability of all medications across all pharmacy outlets was calculated.

The price of each medication was obtained from each pharmacy outlet. For the private pharmacies and other most of the data was taken from the price written on the packages and for the public pharmacies the price data was obtained from the computer system used in dispensing. The local price was changed to US dollars using the exchange rate on the first day of the data collection. On the first day of data collection 1US$=57.3 Ethiopian birr. Median price ratio (MPR) of the medicine was calculated as the median price of the medicine in each sector divided by the international reference price (IRP) of the medicine.

If the MPR of medications had greater than one value, the medications were considered as high price.

MPR was calculated as:

Affordability was calculated based on the daily wage of the lowest paid government worker of Ethiopia required to pay standard dose for each medication for a month period¹¹. For each medication a number of working days necessary for the lowest-paid unskilled government employee to purchase the specific medication for a month course of therapy for chronic conditions and 24 h for acute conditions. The daily wage of the lowest paid government worker of Ethiopia was about 36.67 birr (0.64 USD) per day¹².

Affordability was calculated as:

The results were summarized and presented in tables.

Data quality assurance

To guarantee data quality assurance before data collection, a pre-test was carried out at one private pharmacy to guarantee the clarity of the questionnaire and the data obtained. The questioner was found to be easily understood from the pretest result. The supervisor for this study is the Principal Investigator (PI), who is responsible for overseeing and guiding the research process. The PI ensures that the study adheres to its objectives, methodology, and ethical standards. Additionally, the PI provides mentorship and direction to the research team, facilitates problem-solving, and ensures the quality and integrity of the study outcomes. At the end of each data collection the supervisor checked the data collected for completeness.

After data collection was completed, a random check was done by the supervisor on 20% of the outlets by going back to four randomly chosen pharmacies to collect the same data in order to verify the accuracy of the data gathered by the student, the data collected for assurance was found to be same with the originally collected data by the students.

Ethical consideration

Ethical approval was obtained from the Ethical Review Committee (ERC) (ERB/SOP/582/16/2024) of the School of Pharmacy, College of Health Sciences, Addis Ababa University. The study protocol was performed in accordance with the Declaration of Helsinki. The aim and protocol of the study were fully explained to all participants included in the study and written informed consent was obtained from all participants. All obtained data were treated confidentially.

Operational definition

Other sector in this study includes Kenema Public Community Pharmacies and Red Cross Pharmacies.

Results

Availability

The overall availability of LPG in all sectors was found to be 34.52% ranging from 0 to 100%. The availability of LPGs was 33.73% in the public sector; 40.58% in private sectors; 29.8% in Kenema Pharmacy and 33.99% at Red Cross Pharmacy.

Out of all the LPG medications being surveyed nitroglycerine 5 mg/ml injection, adenosine 3 mg/ml injection, amiodarone 200 mg tablet, verapamil 2.5 mg/ml injection, mannitol 10% injection, glyceryl trinitrate 2.5 mg Tablet (Sustained release), and glyceryl trinitrate 0.5 mg tablet (sublingual) were not available in any of pharmacy outlets surveyed during the study (Table 1).

Table 1.

Overall percentage availability of LPG at public, private, and other sectors in Addis Ababa, Ethiopia, 2024.

Medication (name, dosage form and strength)	Public, (n = 5), (%)	Private, (n = 10), %	Kenema pharmacies, (n = 5), %	Red cross pharmacies, (n = 3), %	Total, (n = 23), %
Adenosine 3 mg/ml injection	0	0	0	0	0
Adrenaline (Epinephrine) 1 mg 1 mL injection	80	40	0	0	30
Amiodarone 50 mg/ml Injection	80	0	0	0	20
Amiodarone 100 mg tablet	80	10	60	0	37.5
Amiodarone 200 mg tablet	0	0	0	0	0
Amlodipine 5 mg tablet	20	90	100	100	77.5
Amlodipine 10 mg tablet	40	90	100	100	82.5
Atropine 0.1 mg/ml injection	0	20	0	0	5
Atropine 1 mg/ml injection,	40	40	0	0	20
Atorvastatin 20 mg tablet	20	100	100	100	80
Atorvastatin 40 mg tablet	20	100	0	100	55
Atorvastatin 80 mg tablet	0	40	20	33.3	23.3
Bosentan 62.5 mg tablet	0	0	0	0	0
Candesartan 16 mg tablet	0	40	100	33.3	43.3
Candesartan 8 mg tablet	0	50	40	0	22.5
Captopril 12.5 mg tablet	0	0	20	0	5
Carvedilol 12.5 mg tablet	0	70	20	100	47.5
Carvedilol 25 mg tablet	0	70	20	100	47.5
Digoxin 0.25 mg/ml in injection	60	20	0	0	20
Digoxin 0.25 mg tablet	80	20	40	0	35
Dopamine hydrochloride 40 mg/ml Injection	100	0	0	0	25
Enalapril 10 mg tablet	40	100	20	100	65
Enalapril 5 mg tablet	80	80	60	100	80
Furosemide 20 mg tablet	20	30	20	0	17.5
Furosemide 10 mg/ml injection	100	90	100	0	72.5
Furosemide 40 mg tablet	80	90	100	100	92.5
Glyceryl Trinitrate, 2.5 mg sustained release tablet	0	0	0	0	0
Glyceryl trinitrate 0.5 mg sublingual tablet	0	0	0	0	0
Hydralazine injection, 20 mg/ml in 1 ml ampoule	80	40	0	0	30
Hydrochlorothiazide 25 mg tablet	60	50	80	100	72.5
Labetalol injection, 100 mg/20 ml	20	40	0	0	15
Labetalol injection, 5 mg/ml	20	0	0	0	5
Lidocaine hydrochloride injection 20 mg/ml	100	50	80	33.3	65.8
Lisinopril 10 mg tablet	0	60	60	33.3	38.3
Lisinopril 20 mg tablet	0	30	0	0	7.5
Mannitol 10% injection	0	0	0	0	0
Mannitol 20% injection	80	40	0	66.6	46.7
Mega-3-fatty acid capsule, 1gm	0	40	0	0	10
Methyldopa 250 mg, tablet	60	10	40	33.3	35.8
Metoprolol 1 mg/ml injection	20	0	0	0	5
Metoprolol 5 mg/ml injection	20	0	0	0	5
Metoprolol succinate 100 mg tablet	0	30	0	0	7.5
Metoprolol succinate 50 mg tablet	20	90	20	100	57.5
Metoprolol succinate 25 mg tablet	40	90	40	100	67.5
Nifedipine 20 mg tablet	100	80	100	100	95
Nitroglycerine 5 mg/ml injection	0	0	0	0	0
Noradrenaline 1 mg/ml injection	40	50	0	0	22.5
Sildenafil citrate 50 mg tablet	0	80	80	100	65
Spironolactone, 25 mg tablet	100	100	100	100	100
Verapamil 2.5 mg/ml in 2 ml injection	0	0	0	0	0
Verapamil 40 mg tablet	20	0	0	0	5
Overall	33.73	40.58	29.8	33.99	34.52

Only six LPG medicines were available in more than 80% of the pharmacy outlets surveyed. Spironolactone 25 mg tablet had the highest availability (100%) followed by Nifedipine 20 mg tablet (95%), furosemide 40 mg tablet (92.5%), amlodipine 10 mg tablet (82.5%), enalapril 5 mg tablet (80.0%) and, atorvastatin 20 mg tablet (80.0%). All the other medicines had less than 80% availability, which is considered to be cut point by WHO for availability of medicines (Table 1).

Price

Among medications available in both public and private pharmacies, 90% had a higher median buyers’ price in private settings compared to public settings, while the remaining 10% had higher median prices in public settings. The MPR for LPG medications used to treat cardiovascular diseases in public sector pharmacies was 3.49, with minimum and maximum values of 0.4 and 1024.82, respectively, and an interquartile range of 1 to 7. In private sector pharmacies, the median MPR was notably higher at 7.24, with a minimum of 1.10, a maximum of 1454, and an interquartile range of 3.43 to 18.32. Moreover, at Kenema Public Community Pharmacies, the median MPR for LPG cardiovascular medications was 2.84, with minimum and maximum values of 0.59 and 41.05, respectively, and an interquartile range of 1.58 to 8.37. Similarly, at Red Cross Pharmacies, the median MPR was 5.21, with a minimum of 0.52, a maximum of 1051.97, and an interquartile range of 1.43 to 18.01. These findings highlight significant price variations between public and private pharmacies, as well as among different public sector settings (Table 2).

Table 2.

MPR in public, private, and other sector in Addis Ababa, Ethiopia, 2024.

Medication (name, dosage form and strength)	MPR
	Public, Birr (USD)	Private, Birr (USD)	Kenema Pharmacies, Birr (USD)	Red cross pharmacies Birr (USD)
Adrenaline (Epinephrine) injection: 1 mg 1 mL ampoule	3.49(0.06)	10.87(0.19)	NA	NA
Amiodarone 50 mg/ml Injection	9.46(0.17)	NA	NA	NA
Amlodipine 5 mg tablet	7.00(0.12)	17.17(0.29)	8.30(0.14)	7.15(0.12)
Amlodipine 10 mg tablet	8.09(0.14)	14.90(0.26)	7.66(0.13)	10.64(0.19)
Atropine 1 mg/ml Injection	5.92(0.10)	6.43(0.11)	NA	NA
Atrovastatin 20 mg tablet	1.36(0.024)	2.73(0.05)	2.27(0.04)	2.52(0.04)
Atrovastatin, 40 mg tablet	1.37(0.02)	2.32(0.04)	NA	1.96(0.03)
Captopril 12.5 mg tablet	NA	NA	0.64(0.01)	NA
Carvedilol 12.5 mg tablet	NA	19.03(0.33)	18.76(0.33)	19.03(0.33)
Carvedilol 25 mg tablet	NA	17.61(0.31)	17.61(0.31)	17.89(0.31)
Digoxin 0.25 mg/ml injection	5.34(0.09)	7.24(0.13)	NA	NA
Digoxin 0.25 mg tablet	2.89(0.05)	12.39(0.22)	2.84(0.05)	NA
Dopamine Hydrochloride 40 mg/ml injection	5.3(0.09)	NA	NA	NA
Enalapril 10 mg tablet	4.45(0.08)	4.28(0.07)	4.45(0.08)	2.74(0.05)
Enalapril 5 mg tablet	1.97(0.03)	5.63(0.09)	4.50(0.08)	3.38(0.06)
Furosemide, 10 mg/ml injection	1.96(0.03)	6.59(0.12)	2.11(0.04)	NA
Furosemide, 40 mg tablet	6.19(0.11)	8.44(0.15)	8.44(0.15)	7.04(0.12)
Hydralazine 20 mg/ml injection	0.60(0.01)	2.98(0.05)	NA	NA
Hydrochlorothiazide, 25 mg tablet	0.4(0.01)	1.10(0.02)	0.59(0.01)	0.52(0.01))
Lidocaine hydrochloride 20 mg/ml injection	42.7(0.75)	186.59(3.26)	41.05(0.72)	34.03(0.59)
Lisinopril 10 mg tablet	NA	3.88(0.07)	2.34(0.04)	18.05(0.31)
Lisinopril 20 mg tablet	NA	25.84(0.45)	NA	NA
Mannitol 20% injection	1024.82(17.9)	1454.33(25.38)	NA	1051.97(18.36)
Methyldopa 250 mg tablet	1.00(0.02)	2.08(0.04)	1.04(0.02)	1.25(0.02)
Metoprolol succinate 100 mg tablet	NA	19.85(0.35)	NA	NA
Nifedipine, 20 mg tablet	0.93(0.02)	3.31(0.06)	0.93(0.02)	1.06(0.02)
Noradrenaline, 1 mg/ml injection	49.58(0.87)	47.93(0.84)	NA	NA
Spironolactone 25 mg tablet	0.55(0.01)	3.55(0.06)	2.67(0.05)	0.55(0.01)
Verapamil, 40 mg tablet	0.67(0.01)	NA	NA	NA
Median MPR	3.49(0.06)	7.24(0.13)	2.84(0.05)	5.21(0.09)
Min MPR	0.40(0.01)	1.10(0.02)	0.59(0.01)	0.52(0.01))
Max MPR	1024.82(17.88)	1454.33(25.38)	41.05(0.72)	1051.97(18.36)
25th Percentile	1(0.02)	3.43(0.06)	1.58(0.03)	1.43(0.02)
75th percentile	7(0.12)	18.32(0.32)	8.37(0.15)	18.01(0.31)

1USD = 57.3 Ethiopian Birr. MPR median price ratio, NA not applicable.

Affordability

Majority of the medicines were found to be unaffordable, costing more than one-day wage in all sectors. In the public sectors only three medications (dopamine hydrochloride, 40 mg/ml injection, nifedipine 20 mg tablet, and hydrochlorothiazide 25 mg tablet) were found to be affordable. In both Kenema and Red Cross pharmacies, nifedipine, 20 mg tablet and hydrochlorothiazide 25 mg tablet were found to be affordable. In private retail pharmacies all medications were found to be unaffordable.

The top three unaffordable medications in public sectors were metoprolol, amiodarone, and labetalol requiring 82.96, 28.14 and 20.13 days’ wage of the lowest paid government employee respectively. The top three unaffordable medications in private community pharmacies were metoprolol, candesartan, and carvedilol requiring 343.61, 108.73 and 85.90 days’ wage of the lowest paid government employee, respectively. In Kenema pharmacies also metoprolol takes the lead as the top unaffordable drug with 352.44 days’ wage of the lowest paid government employee followed by candesartan, and carvedilol requiring 94.49 and 84.67 days’ wage of the lowest paid government employee respectively. The top three unaffordable medications in Red Cross pharmacies are similar to the Kenema pharmacies which were metoprolol, carvedilol, and candesartan requiring 193.89, 85.90, and 52.89 days’ wage of the lowest paid government employee respectively (Table 3).

Table 3.

Number of days’ of wages of the lowest-paid government worker needed to purchase standard treatments in Addis Ababa, Ethiopia, 2024.

Medication (name, dosage form and strength)	DDD (mg)	Number of days for a standard treatment	Number days wages require to pay in public sectors	Number days wages require to pay in private sectors	Number days wages require to pay Kenema pharmacies	Number days wages require to pay red cross pharmacies
Adrenaline 1 mg/ml injection	0.5	1	1.05	3.27	–	–
Amiodarone 50 mg/ml injection	200	1	9.86	–	–	–
Amiodarone 100 mg tablet,	200	30	28.14	56.45	30.93	–
Amlodipine 5 mg tablet	5	30	2.00	4.9	2.37	2.05
Amlodipine 10 mg tablet	5	30	1.55	2.86	1.47	2.05
Atrovastatin 20 mg tablet	20	30	2.66	5.32	4.42	4.91
Atrovastatin 40 mg tablet	20	30	2.29	3.89	–	3.27
Atrovastatin 80 mg tablet	20	30	–	9.29	10.84	9.06
Candesartan 16 mg tablet	8	30	–	54.36	59.68	52.85
Candesartan 8 mg tablet	8	30	–	108.73	94.49	–
Captopril 12.5 mg tablet	50	30	–	–	8.51	–
Carvedilol 12.5 mg tablet	37.5	30	–	85.90	84.67	85.90
Carvedilol 25 mg tablet	37.5	30	–	54.36	54.36	55.22
Digoxin 0.25 mg/ml injection	0.25	1	2.71	3.68	–	–
Digoxin 0.25 mg tablet	0.25	30	2.29	9.81	2.25	–
Dopamine Hydrochloride 40 mg/ml injection	500	1	0.98	–	–	–
Enalapril 10 mg tablet	10	30	2.13	2.05	2.13	1.31
Enalapril 5 mg tablet	10	30	1.15	3.27	2.62	1.96
Furosemide 20 mg tablet	40	30	3.47	5.24	4.09	–
Furosemide 10 mg/ml injection	40					–
Furosemide, 40 mg tablet	40	30	1.8	2.45	2.45	2.05
Hydralazine 20 mg/ml Injection	100	1	10.53	51.81	–	–
Hydrochlorothiazide 25 mg tablet	25	30	0.45	1.23	0.65	0.57
Labetalol 100 mg/20 ml Injection	600	1	16.14	57.27	–	–
Labetalol 5 mg/ml Injection	600	1	20.13	–	–	–
Lisinopril 10 mg tablet	10	30	–	4.74	2.86	22.09
Lisinopril 20 mg tablet	10	30	–	14.11	–	–
Mega-3fatty acid 1gm capsule	4	30	–	62.83	–	–
Methyldopa, 250 mg tablet	2	30	15.71	32.72	16.36	19.63
Metoprolol 1 mg/ml Injection	150			–	–	–
Metoprolol 5 mg/ml Injection,	150			–	–	–
Metoprolol succinate 100 mg tablet	150	30	–	61.97	–	–
Metoprolol succinate 50 mg tablet	150	30	45.40	134.99	110.44	134.99
Metoprolol succinate, 25 mg tablet	150	30	82.96	343.61	352.44	193.89
Nifedipine, 20 mg tablet	30	30	0.86	3.07	0.86	0.98
Noradrenaline 1 mg/ml injection	6	1	12.27	11.86	–	–
Spironolactone 25 mg tablet	75	30	3.44	22.09	16.57	3.44
Verapamil 40 mg tablet	240	30	8.84	–	–	–

DDD defined daily dose.

Discussion

This study has addressed the availability, price and affordability of 40 LPG essential medicines with different dosage forms and strengths used to treat CVDs. The results of the current study showed that the overall availability of LPG medication to treat CVDs in Addis Ababa was 34.52% which is much lower than WHO’s 80% availability target for the necessary medicines to treat non-communicable disease (NCDs). The 80% target availability of necessary medicines to treat non-communicable disease set by WHO is an important input to achieve a 25% relative reduction in premature mortality from chronic NCDs by 2025³¹. This study and previous few studies indicated that, it may be difficult for Ethiopia to achieve the target goal in the period specified^32–34.

In a systemic review done on a data from 84 surveys in 59 countries that used WHO’/HAI survey methodology showed that the mean availability of the drugs used to treat CVDs was 54% in LMICs and 60% in high‐ and upper‐middle‐income countries³⁵. The result from the current study shows that the availability is even much lower than the results from the above systemic review.

The availability of LPG essential medicines used to treat CVDs at public and private pharmacy outlets is 34.52% and 40.58% respectively. In other sectors the availability of LPG is 29.8% and 33.99% in Kenema and Red Cross pharmacies respectively. Unlike previous studies on different group of medicine in Ethiopia, LPG essential medicines used to treat CVDs had better overall availability in the private retail pharmacies than in another sector^33–35. This could be because unlike the other chronic disease, CVD has higher prevalence and private drug retailers are more aware of the disease and its prevalence, which drive private companies to be involved in selling of the products which has large economy of sales than lesser prevalent chronic disease like cancer, psychiatric disease and seizure disorder medicines. On the other hand, similar with this study several studies done in other LMICs on medicine availability in the public and private sector, found better availability in public sectors than in the private sectors^35–38. Private pharmacy work with a motive of making profits in a competitive environment, they tend to work hard to establish an efficient supply chain management and procurement system resulting in a better stoke in medications with high demand among the population.

The unavailability of nitroglycerin, both as an injection and sublingual tablet, in all surveyed sectors is concerning given its critical role in managing acute decompensated heart failure and acute coronary syndrome. Despite the increasing prevalence of these conditions, the lack of access to this essential medication can significantly impact patient outcomes³⁹. This is also different from other LMIC country like Afghanistan which had better availability of nitroglycerin tablet (77%)⁴⁰.

The pricing of medications in both public and private sectors often exceeds IRP, with over 80% of drugs in private sectors and 65.22% in public sectors being priced higher. Notably, 41.37% of medications in the private sector have median prices that are two times higher than those in the public sector, while 24.14% are three times higher. This disparity highlights the need for effective pricing policies. Similar study findings showed that the private sector consistently shows higher prices, with significant portions of medications priced at two to three times the public sector’s rates⁴¹. The implementation of IRP has been shown to lower local prices, particularly in the public sector, where 92% of products had the lowest prices compared to international benchmarks⁴². In addition, regulated markets can offer lower prices than deregulated ones, suggesting that effective regulation can enhance affordability⁴³.Due to low availability of medications in public sectors patients are forced to buy from the private retail pharmacies with very high price. For example, to buy a single vial of lidocaine or Digoxin 0.25 mg tablet from private pharmacy, patients need to pay a price three or four times more than public sector prices. Similarly WHO/HAI survey in more than 70 countries found that private sectors usually charge more than two times higher price than the public sectors¹. Higher costs required to establish private retail outlet and interest to make more profit could be reason for higher price in private sector.

The affordability of medications for cardiovascular diseases remains a significant challenge, particularly in low- and middle-income countries (LMICs). While some medications like dopamine injection, hydrochlorothiazide, and nifedipine are deemed affordable, many essential drugs, especially in the private sector, are not accessible to the majority of the population. This finding is in line with a study done in other LMICs where the median cost of vital medications can reach up to 6 days’ wages, making them unaffordable for many⁴⁴. In addition, in Balochistan, Pakistan, essential LPG medications are more affordable, with mean availability of 49.4% compared to only 9.8% for originator brands⁴⁵. In Kerala, India, the monthly cost of LPGs was found to be manageable, costing less than 1.2 days’ wages for the lowest-paid workers⁴⁶.

Metoprolol succinate 50 mg tablet is one of the commonest medications used in the treatment of heart failure. However, a patient with a heart failure who has been prescribed with metoprolol succinate tablet is required to pay more than a 45 and 134 days’ wage in public and private sectors respectively to purchase a 1 month medication. Similarly, emergency medications such as noradrenaline injection 1 mg/ml, labetalol injection 100 mg/20 ml and hydralazine injection 20 mg/ml, required to have at least a 10 days’ wage to purchase 24-h duration medication need. The unaffordability in this study was very much greater than other LMIC¹.

Additional most CVDs require combinations of medicines which further increase unaffordability of the medications. The uncontrolled inflation rate, civil unrest, very low salary rate in Ethiopia has contributed to unaffordability of medicines^47–49.

From the current and previous studies indicate most essential medications are not accessible in Ethiopia^33–35. The inaccessibility of medications significantly hampers the healthcare system’s ability to address health issues effectively. This situation arises from various factors, including high costs, inadequate supply chains, and regulatory challenges, which collectively undermine the provision of essential medicines⁵⁰.

Limitations of the study

A notable limitation of this study is its geographic focus, as it was confined solely to the capital city, Addis Ababa. This restricted scope may not fully capture the extent of the issue across the country, where the situation could potentially be more severe in regions with limited access to healthcare infrastructure, fewer pharmacies, and weaker regulatory oversight. Expanding the study to include rural and underserved areas would provide a more comprehensive understanding of the disparities in medication pricing and accessibility throughout the country. In addition, the international price comparisons are influenced by several assumptions, which can impact the results; therefore, they should be considered as indicative rather than definitive and serve as a basis for further investigation. The MPRs were calculated using the available 2015 MSH IRPs.

Conclusion

In conclusion, the study underscores significant challenges in the availability, pricing, and affordability of LPG medications to treat CVDs in Ethiopia. The overall availability of LPG medicines across all sectors was suboptimal at 34.52%, with variations observed between public (33.73%) and private (40.58%) sectors, and within Kenema pharmacies (29.8%) and Red Cross pharmacies (33.99%). Pricing analysis revealed that medication prices were consistently higher in private pharmacies compared to public ones, with a median Medicine Price Ratio (MPR) of 7.24 in private pharmacies versus 3.49 in public pharmacies. Kenema and Red Cross pharmacies also exhibited lower MPRs than private outlets but higher than public sector pharmacies. Affordability emerged as a pressing concern, with the majority of medications deemed unaffordable across all sectors. Addressing these gaps will require concerted efforts to improve supply chain efficiency, regulate pricing mechanisms, encouraging generic and local manufacturing fully implementing health care financing and enhance accessibility in both public and private sectors. Policymakers should prioritize interventions that expand the availability of essential medications and ensure affordability for all.

Author contributions

R.M. and M.G.B. conceptualized and designed the study, wrote the original manuscript, final version of the manuscript and performed analysis and interpretation of data. F.H., M.F.S., A.M.B. and C.K. assisted in the data collection, study design, manuscript evaluation, edited and wrote the final version of the manuscript. All authors have made an intellectual contribution to the work and have approved the final version of the manuscript for submission.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.