AbstractInadequate access to medicines affected by un-controlled prices is a major concern in developing countries, including Pakistan, which lacks comprehensive data on medicine prices. Thus, the objective of this study was to evaluate the prices, availability and affordability of essential medicines in Lahore division, Pakistan.

• Official List Of Medicines
• List Of Medicine Drugs

The survey was undertaken from November, 2016 till March, 2017 by including 50 medicines, 14 from the WHO/HAI core list and 36 supplementary medicines from national essential medicine list (NEML) at public (n = 16) and private (n = 16) health facilities. The prices, availability and affordability of selected medicines were measured using a variant of the WHO/HAI standard methodology available on HAI website and WHO/HAI manual. A questionnaire was used for data collection from Lahore division. The prices were compared to International reference prices (IRPs) and the daily wage of a lowest paid unskilled government worker was used to calculate medicine affordability. Data suggested poor availability of originator brands (OB) in public and private sector facilities, i.e., 6.8% and 55.0%, respectively. Similarly, low availability was observed for lowest price generics (LPGs), both in public (35.3%) and private sector (20.3%) facilities–far below the WHO global action plan targets of 80% availability of essential medicines by 2025.

In private sector, 53% OB and 38% LPG medicines were found excessively priced. The cost of standard treatment with OBs was unaffordable, i.e., above a single daily wage (1.4 day’s wages) was demanded to purchase the standard treatment for the selected diseases in case of OBs medicines. Whereas, the cost of LPGs medicine required to purchase the standard treatment of the selected diseases was 0.6 day’s wage (median), below a single daily wage. In conclusion, access to essential medicines, especially at public sector facilities was affected by low availability, particularly of OBs in comparison to LPGs. Thus, the better availability of LPGs might be a rational basis of transition into a generic system of prescribing that may improve the availability and accessibility of essential medicines in Lahore division. Medicine prices in Lahore division were found higher in comparison to IRPs.

Thus, the efforts must be made to formulate patient’s pocket friendly drug pricing policy that favors price cuts and improves affordability. Citation: Saeed A, Saeed H, Saleem Z, Fang Y, Babar Z-U-D (2019) Evaluation of prices, availability and affordability of essential medicines in Lahore Division, Pakistan: A cross-sectional survey using WHO/HAI methodology. PLoS ONE 14(4):e0216122.Luzia Helena Carvalho, Instituto Rene Rachou, BRAZILReceived: June 6, 2018; Accepted: April 15, 2019; Published: April 25, 2019Copyright: © 2019 Saeed et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Data Availability: All relevant data are within the paper and its Supporting Information files.Funding: The authors received no specific funding for this work.Competing interests: The authors have declared that no competing interests exist.

IntroductionIn developing countries, the budget allocated to the purchase of medicines contributes significantly to the overall health care costs and may account for almost 50–95% non-personnel costs. In Pakistan, 32% of the health expenditure is borne by public sector, while 64% is borne by patient’s out of pocket payments that may account for unaffordability of medicines in this region.

Thus, the higher prices of medicines are considered as one of the major barriers to access medicines, even the essential medicines. Whereas, availability and affordability are considered to be the key prerequisites for universal access to medicines.Therefore, the estimation and comparison of medicine prices affecting medicines availability and affordability would be instrumental in framing a rational drugs pricing policy. A very few studies have been reported from Pakistan that deal with the ever-growing issue of increased/higher drug prices which may impact the affordability and availability of drugs. Thirteen percent (13%) of Pakistan’s population lives below the poverty line, i.e. Less than 1USD per day, the earning that is not sufficient to obtain even basic medicines such as aspirin for long term use.In this context, the ministry of health, government of Pakistan had been providing free medicines in the public sector hospitals, nevertheless, the poor availability of medicines in public health facilities might compel the patients to get their medicines from private sector medicine retail outlets where they are supposed to pay from their own pockets. To improve this situation, Drug Regulatory Authority of Pakistan (DRAP), after its formation in 2012, introduced its first ever drug price policy in 2015 to ensure transparent mechanism of price fixation in a bid to improve the availability and affordability of medicines. As a control measure, annual increase in medicine prices was linked with Consumer Price Index (CPI), announced by Pakistan Bureau of Statistics, Government of Pakistan, with an allowable price increase of 4% for schedule drugs and 6% for non-schedule drugs.

A few reports from Pakistan published in 2014 and 2016 claimed that the medicine prices were increased up to 100% –, which was justified by pharmaceutical manufacturers mainly due to increase in operational costs associated with depreciation of Pak rupees against US dollar. Pakistan utilizes external reference pricing system by taking into account medicine prices of other countries as reference to set and control its medicine prices, which include, India, Bangladesh, New Zealand and United Kingdom, yet the prices are high and unaffordable.Very few studies have been reported on Pakistan’s Pharmaceutical pricing, in fact, there is only one study published in 2006 on availability and affordability of essential/medicines. Therefore, there is an urgent need to evaluate the prices, availability and affordability of essential medicines in this region at different levels of health care. Thus, the objective of this study was to determine the prices, availability and affordability of originator brands and generic equivalents of the selected essential medicines in both public and private sector health facilities of the most populous division of Pakistan, the Lahore division. The study also compared these prices with international reference prices of selected countries of the region.

Study designA cross-sectional study was conducted by employing a variant of World Health Organization (WHO) /Health Action International (HAI) methodology in Lahore Division, Pakistan. Data on medicine prices, availability and affordability for specific list of medicines was collected from four districts of Lahore division, i.e., Lahore, Kasur, Nankana Sahib and Sheikhupura. The sampled health facilities were surveyed from November 2016 to March 2017 (referring to the fiscal year 2016–17, as the annual budget is announced in June by the government of Pakistan).

Macrograph depicting sampling sectors of the study along with district wise distribution of population, total hospitals and sampled public sector medicine outlets.DHQ; district head quarter hospital, THQ; tehsil head quarter hospital and BHU; basic health unit. In Lahore district, 2 Tertiary care hospitals are given the status of DHQ, one of these DHQs was taken as survey anchor. The Red Cross symbol indicates a public sector medicine outlet and the prescription symbol indicates a private sector medicine outlet. Survey regionPakistan consists of four provinces which are sub-divided into several administrative units called “divisions”, each division is further sub-divided into districts, then districts into tehsils and tehsils into union councils.

The survey region, Lahore division, is situated within the largest province of Pakistan (in terms of population), i.e. Punjab, which consists of four districts with a population of 16.28 million as of 2017. According to standard WHO/HAI methodology, six regions must be selected as “survey areas”—the administrative units (e.g. Provinces, divisions, cities, districts or countries) with estimated population coverage of about 0.1 to 0.25 million. All survey areas (e.g.

Four districts in our case) must be reachable in a day from the main urban center (e.g. Lahore district in our case). However, we customized the methodology and used a variant of the standard methodology because Lahore Division consisted of four administrative divisions/districts, thus instead of six survey areas, four regions were selected as survey areas. Moreover, the number of NGO sector facilities were very few to be considered for analysis, none in Kasur, Sheikhupura and Nankana Sahib, (because the number of these sector facilities should be four according to the WHO/HAI methodology), thus NGO sector facilities were not included in the survey. Sampling of medicine outlets for surveyData were collected from a sample of public sector medicine outlets and from registered retail pharmacies (private sector) in Lahore division. According to the standard methodology of WHO/HAI, 4 public sector outlets must be selected from each survey area.

In public health sector of Pakistan, tertiary care services are provided by teaching hospitals, secondary healthcare services are usually provided by district head quarter (DHQs) and tehsil head quarter (THQs) hospitals, while basic healthcare units (BHUs) provide primary level of healthcare. But there is one exception in case of Lahore district (a larger district as compared to other three districts in the study) i.e. Two tertiary care hospitals are given the status of DHQs by the ministry of health. The DHQs are located in main cities whereas THQs and BHUs are located in peripheral cities/towns.The standard methodology suggests to include the main public sector hospital from each region as survey anchor (DHQs in our case) and to select other public sector outlets randomly which are within 3 hours travel from the survey anchor. Since Lahore division is divided into 4 districts, therefore, we selected a total of 16 public sector hospitals, 4 from each district. From Lahore district, all 4 available DHQs and THQs were selected i.e.

2 DHQs (tertiary care hospitals) and 2 THQs (secondary care hospitals). In district Kasur, where 4 secondary healthcare public sector hospitals are available, which include 1 DHQ and 3 THQs, all of these where surveyed.

In Sheikhupura district, where total 5 secondary healthcare hospitals are available, which include 1 DHQ and 4 THQs, after selecting the DHQ as survey anchor, we selected 3 THQs randomly to complete the total of 4 hospitals in this survey region. In Nanakana Sahib district, there were two secondary healthcare hospitals. Thus, because of the lesser number of THQs in Nankana as compared to other three districts, only option left was to select 2 BHUs located within 3hrs drive from the main public hospital (i.e. DHQ) to complete 4 public sector outlets in this region.Overall, 14 out of 32 public sector tertiary and secondary care hospitals were surveyed along with 2 BHUs as public sector medicine outlets.From private sector, retail pharmacies were selected as per WHO/HAI methodology. The criteria suggests to include one private pharmacy outlet within 10 Km range of each public sector health facility. In this way, a total of 16 private retail pharmacies were selected which included 1 private retail pharmacy near to each selected public sector medicine outlet.

It is also noteworthy that each survey unit (which includes one public and one private sector medicine outlets) was located in different tehsils (administrative sub-division) of a particular district. Thus, out of 17 tehsils in Lahore division, 16 tehsils were included in the survey ensuring fair representation of the division Lahore. As a result, 32 healthcare facilities/medicine outlets were surveyed in the study. Medicine selectionAccording to WHO/HAI methodology, the selection of medicine for the surveys should include core and supplementary list of medicines selected by each country based on local needs and disease burden. The list of survey medicines included 14 core essential medicines from WHO/HAI core list for local and international comparison as suggested by WHO/HAI methodology standards. Medicines with specific formulation, dosage forms, and procured via donations were not included in the study taking into account their infrequent usage for specific diseases and procedures, non-enlistment in the NEML and difficulty in price estimation of donated medicines. The survey also included 36 supplementary medicines, selected based on local population disease needs, by taking into account WHO/HAI methodology standards.

Therefore, most of the medicines were chosen from Pakistan’s national essential medicines list (NEML) 2016 considering local disease burden. Thus, out of 50 medicines, 46 surveyed medicines were part of Pakistan’s NEML 2016, Table A in. Data collection and analysisData were collected by trained data collectors (Pharmacy students) who visited the retail medicine outlets and recorded the availability and prices of the selected medicines using a data collection form (Appendix 1). The form was used to get the required drug pricing information from each outlet. The availability of each medicine was marked after physical checking and proper documentation. The prices of originator brands (OBs), the original patented pharmaceutical products, and lowest price generics (LPGs) available in the facility at the time of survey were collected from 16 public and 16 private medicine outlets.Data were entered in Excel Workbook which is available on HAI website along with the WHO/HAI manual. Availability, median price ratios and affordability of selected medicines were calculated according to the standard WHO/HAI methodology.

All prices were converted into US dollars using the exchange rate from OANDA (Canada) currency converter on November 05, 2016, the first day of survey i.e. 1USD = 103.7020 PKR. Medicines availability.Availability of each medicine was documented as percent availability of surveyed medicines in a facility on the day of data collection. Availability was documented as follows; Absent: 0% of facilities, these medicines were not found in any facility; Low: 80% of facilities, these medicines were found in most of the facilities. International reference price and median price ratios.Medicines prices were calculated in terms of median price ratios (MPRs). Median Price Ratio is the ratio of median local unit price obtained during the survey to the international reference unit price, estimated mainly to facilitate international price comparisons.

MPR was obtained using the formula given below;Median Price Ratio (MPR) = Median local unit price / International reference unit priceEmploying MPRs, medicines can be categorized as high or low-cost medicines—higher MPR means higher price. MPR of more than 5 for private sector and more than 2 for public sector has been considered as cut off values for fairly high prices by many studies. Whereas, the MPR of greater than 2 indicates that the local medicine prices were twice compared to international reference prices. Still, there are no well-defined rules for the interpretation of MPRs because number of key medicine price components vary among different countries, such as different market size and penetration, medicines pricing mechanisms, accessibility, taxation and scales of economy. So, we took an MPR of more than 1 for public sector and MPR of more than 2 for private sector as a cut off value for excessively priced medicines, as this criterion has already been used by previous study conducted in Pakistan using similar methodology. WHO & HAI recommend the use of Management Sciences for Health (MSH) International Drug Price Indicator Guide as the source of reference prices. In this study, Price Indicator Guide 2015 was used as a source of international reference prices of the survey medicines.

The MSH prices are net prices mostly obtained from non-profit suppliers to the developing countries and NGOs. In this study, the median unit supplier prices were used. These MSH reference prices are relatively low and offer a very useful standard to compare locally available medicines. Affordability.Medicine affordability was estimated by considering the number of working days (daily wages) of the lowest paid unskilled government employee that enable him/her to purchase the course of standard treatment for common conditions with selected medicines.

If in a month, a patient spends more than one day’s wage for getting the standard treatment then it was considered unaffordable. Patient’s affordability of standard treatments for different diseases was calculated by taking into account the salary of lowest paid government worker for the fiscal year 2016–17, 14000 Pak Rupees/month (with effect from 01 July 2016). A total of 12 medicines were considered for affordability calculation, including medicines from WHO core list used for most common chronic diseases, such as cardiovascular diseases and diabetes. In case of medicines for chronic diseases, total treatment duration of 30 days was considered for affordability calculations, since the affordability was estimated for a month.

The number of units of selected medicines for a standard treatment and total duration of therapy were entered into the WHO/HAI preprogrammed Excel workbook as suggested by WHO/HAI methodology. Both the median treatment price (in local currency) and the number of daily wages spent on the treatment were automatically calculated for both private and public sectors. Treatment that cost only 1 day income or less (1 month supply in case of chronic conditions) was considered affordable. Availability of medicines in public and private sectorData on the availability of medicines in public and private sector facilities are summarized in. We found that the overall availability of surveyed medicines in public sector was 6.8% only (mean percent availability) for originator brands (OBs) and 35.3% (mean percent availability) for the lowest price generics (LPGs). Compared to public sector, the availability of medicines in private sector retail pharmacies for 50 surveyed medicines was relatively better in case of OBs i.e. 55% and relatively lower in case of LPGs i.e.

20.3%, Table B in. Individual medicines availability in outlets.In public sector, the mean availability of LPGs was 35.3%, while it was 20.3% in private sector facilities, Table B in. In public sector, only 5 out of 50 LPG medicines, surveyed in the study had adequate availability, i.e.

80%, while 6 medicines—Amitriptyline, Fluphenazine Decanoate, Gliclazide, Hydrochlorothiazide, Indinavir, Zidovudine were not available at any facility. The overall availability of OBs in public sector was as low as 6.8% in public sector while it was 55% in private sector facilities. Moreover, in more than 75% public sector facilities not even a single originator brand was available, Table C in. In private sector, the mean availability of all and essential medicines was 55% for OBs and 20.3% for LPGs. Four medicines, i-e., Indinavir, Lovastatin, Nevirapine and Zidovudine (LPGs and OBs), were absolutely not available in all selected outlets (both public and private sectors), Table C in. Likewise, out of all the surveyed LPG medicines, eight medicines were not available at any outlet, including Diazepam, Digoxin, Lovastatin, Methyldopa, Spironolactone, Nevirapine, Indinavir and Zidovudine. The medicines with availability of more than 80% were Atenolol, Captopril, Ceftriaxone Injection, Amoxicillin 250mg and Ciprofloxacin, Table D in.

Medicines availability at various health care levelsIn Public sector, availability of medicines at particular level of care i.e. Primary, secondary and tertiary healthcare units, was also estimated and only those medicines were included for calculation which were supposed to be available at every level of care according to Pakistan’s NEML. At primary level, of all the medicines, not a single OB was available, while only 25.8% LPG medicines were available, Table C in.

At secondary health care level, availability of medicines improved in comparison to primary level, i-e., 7.1% for OB and 35.2% for LPG medicines. At tertiary level, the availability of medicines was even better than the primary and secondary health care levels, i-e., 12% for OB and 50% for LPG medicines, Table C in. However, ideally the percent availability should be more than 80% as defined by the standard WHO/HAI methodology, but none of the healthcare facilities, irrespective of the type, under this analysis fulfills that criterion.

Patient prices in private sectorIn public sector heath facilities, patient prices i.e. The prices paid by patients to get the medicines, were not estimated due to the provision of free medicines. Data revealed that in private sector overall MPRs for all the surveyed medicines, compared to MSH (management science health) 2015 reference prices, varied between 0.42 and 60.63 i.e.

The prices in Pakistan were higher, somewhat between 2.5 times lower to 60 times higher, than the international reference prices, Table E in. The price variations were higher for OB products, i-e., between 0.58 and 60.63 in terms of median MPR, while the variations were lower for LPG medicines, i.e. 0.42 to 19.96. Additionally, almost 53% OBs and 38% LPGs fell in high priced medicine category i.e. Having MPR of more than 2, Table E in.

The top five OBs with highest MPRs include, Fluconazole (60.63), Omeprazole 20mg (34.04), Aciclovir (20.21), Atorvastatin (18.11) and Ceftriaxone inj. The top five LPGs with highest MPRs, include Fluconazole (19.96), Omeprazole 20mg (10.50), Diclofenac (7.50), Ceftriaxone inj.

(7.50) and Atorvastatin (3.36). Affordability of standard treatments at private facilitiesOn an average, the cost of standard treatment was equivalent to 1.4 day’s wages (median) for OBs and 0.6 (median) for LPG medicines. Notable treatments exceeding the minimum daily wage limits for OBs included, Simvastatin (4.3), Omeprazole (3.2), Bisoprolol (1.5), Ciprofloxacin (1.5), Insulin Isophane (NPH) (1.4) and Insulin Neutral Soluble (Regular) (1.4)–all were considered unaffordable. However, the treatment with LPG medicines seems affordable and were either equal or less than one day’s wage, though with poor availability (20.7%).

It is pertinent to mention that this calculation was done by taking into account the standard dose of individual medicines, if a patient is taking more than one medicines then the bar will go even higher making the treatment completely out of reach for most of the patients. DiscussionThe present study clearly demonstrated that both OBs and LPGs of the surveyed essential medicines were excessively priced in private sector pharmacies in Lahore Division, the most populous division of Pakistan. Moreover, the present survey was carried out over an extended period of time (i.e.4-5 months) at different health facilities, therefore, it provided a realistic assessment of the overall situation faced by the patients on daily basis. The overall availability of OBs was extremely poor in public sector medicine outlets in comparison to private sector medicine outlets, while for LPGs it was better compared to OBs, but still very skimpy in both sectors.

Similarly, the treatment of common diseases was found affordable with LPGs but unaffordable with OBs. When we compared our data with other middle-income countries (Egypt, India, Lebanon and China), Pakistan was positioned at number three, after India and Lebanon, in terms of medicine’s affordability, though these differences seemed trivial due to small sample size.Availability and affordability are considered the key requisites for universal access to medicine ,. In 2004, 12–13 years back, a study from Pakistan reported that OBs were not available in public sector and only 3.3% (median percent availability) LPGs were available at public sector facilities. Despite divisional/regional focus of our study, data of the current study was compared with nation wide study on medicine prices, since the medicines in Pakistan are priced by central government and are supposed to be supplied and sold at similar prices across the country.In this regard, compared to the situation in 2004, the data from the present study suggested that the overall availability of surveyed medicines in public sector exhibited improvements—significant in case of LPGs (35.3%) and fairly inadequate in case of OBs (6.8%). Probably, these improvements are attributable to the establishment of DRAP in 2012 which resulted in the enforcement and procurement of NEML based system of medicines coupled with increase in the number of working pharmacists in public sector facilities due to surge in hiring. However, DRAP’s bid to exercise the statutory powers in order to regulate the prices of medicines were opposed by manufacturers on the premise of having poor revenues due to limited whole sale markups, i-e., 2 to 10%. Thus, in spite of DRAP’s approval, between June–August, 2016, to increase the prices 4 times, many companies increased up to 5 times and were adamant on upholding their decision by getting stay orders from Lahore High Court.

Notwithstanding the improvements in drug regulation, the availability of medicines was still below the optimal benchmark, i.e. 80%, in Lahore division, Pakistan.

However, when compared with primary and secondary health care facilities, the availability of medicines was relatively better at a tertiary care facility of Lahore, but still below the WHO touchstone of 80% regarding availability of essential medicines.Data further suggested that compared to public sector, the availability of surveyed medicines was higher in private sector. While in 2004, the availability of medicines in private sector was reported as 54.2% for OBs and 31.3% for LPGs, which has now been improved to 55.0% in case of OBs and considerably reduced to 20.3% in case of LPGs. The reduced availability of LPGs in recent year suggested that the patients are compelled to purchase the expensive medicines in private sector due to non-availability of cheaper medicines compared to previous years.

Despite the enforcement of NEML based procurement system in public sector hospitals and implementation of DRAP pricing policy in 2016, it became practically non-viable for many pharmaceutical companies, including multinationals, to manufacture pharmaceuticals or sell them to public funded hospitals at cheaper prices. Seemingly, the major reason could be the unceasing stalemate between pharma companies and DRAP on price regulation, which may have resulted into stock outs of essential medicines, especially in public funded hospitals, affecting availability. Therefore, it is reasonable to assume that the majority of Pakistan’s population have poor access to cheaper medicines (LPGs), simply because most of the patients, i-e., 67% or more consult private physician and often seek treatment from a private pharmacy rather than a basic or rural health unit. Other reasons for poor availability of LPGs could be the budgetary constraints, poor regulation of medicines in terms of procurement, insufficient NEML driven procurement policies (to purchase lowest price medicine), fragile supply chain and non-functional pharmacy and therapeutics committees.It has been reported previously that the overall MPRs in private sector of Pakistan varied from 0.20 to 26.20 in 2004, i.e., from 5 times lower to 26 times higher prices as listed by MSH. Data from the present study suggested that MPRs in private sector exhibited significant variation from 4 times lower to 60 times higher for all the surveyed medicines taking into account MSH 2015 reference prices. Additionally, of all the medicines included in the survey, 53% of OBs and 38% of LPGs were found overpriced i.e. Having MPR of more than 2.

Official List Of Medicines

Despite the establishment of DRAP and more comprehensive drug pricing policy in Pakistan, the increase in medicine prices over the past decade could be due to several factors, such as poor implementation and regulation by DRAP, devaluation of Pakistani rupee, lack of entry agreement, value-based pricing, intended benefits to importers and multinational pharma companies, and imbalance between affordability and profitability. The better availability of OBs in private sector might be attributed to frequent prescriptions of brands by the doctors and incentive driven purchase/stocking of these brands at pharmacies by the pharmacists, which possibly affect the availability of LPGs in private sector.In Pakistan, approximately one third of the population lives below the national poverty line and 36.9 million out of 185 million people live with or earn less than 325.05 Rupees per day–less than the daily wage affordability calculation i.e. 466.6 Rupees. This clearly indicates that basic essential treatments for the prevalent chronic diseases will be completely out of reach for millions of Pakistanis. Therefore, the generic prescribing must be mandated at least in public sector.

The doctors must be trained to work out the cost-effective therapy for the patients by emphasizing generic prescribing. Seminars and workshops should be arranged for pharmacists and medicines procurement officers to train them in the efficient management of supply chains.There could be several implications for policy makers that need to be accentuated while devising medicine pricing policy. The government should ensure and evaluate NEML based procurement which must be revised on regular basis.

Innovative financing mechanisms that support the sale of a group of essential medicines in private sector retail pharmacies. There should be more efficient procurement system duly supported by sustainable financing to improve the availability of essential medicines at public medicine outlets.

Moreover, drug regulators in collaboration with health department should ensure focused resource utilization on selected generic essential disease medicines instead of broad range of originator brand and local generic medicines to ensure improved availability of priority treatments. Similarly, lowering procurement prices, promoting and implementing differential pricing for countries like Pakistan, exempting essential medicines from tariffs and taxes, and promoting local manufacturing of essential brands by subsidizing raw material purchase would improve essential medicine availability and affordability for the sick. Combining together, the above stated recommendations along with consumer awareness campaigns about medicine prices and encouraging regressive markups rather than progressive markups on costly medicines can be instrumental in bringing down the prices of medicines.Thus, the poor availability of essential medicines in the public sector of Pakistan can be translated into limited or no access to medicines for the poor.

Probably, the poor adherence to pricing policy is also one of the major reasons of failure to control prices of drugs and inaccessibility of essential medicines to the people of Pakistan. Moreover, many retailers are overpricing the drugs and are not selling them on the maximum retail prices fixed by the drug pricing committee. So, a system should be devised to regularly monitor the MRPs of medicines in private sector and to ensure adherence to pricing policy. These assessments also necessitate such comparisons to be done at a larger scale. International comparison of affordability of standard treatmentA total of 4 middle income countries, i.e.

India, Egypt (lower middle income countries), China & Lebanon (Upper middle income countries) were selected to compare the affordability with that of Pakistan. India resides in the South Asian region—Pakistan’s neighboring country having almost similar medicine pricing and procurement systems. Pakistan also considers India’s medicine pricing as an external reference for its own medicine pricing. Pakistan is also a member of WHO Eastern Mediterranean Region which include Egypt and Lebanon. China borders Pakistan’s northeast side and falls under the category of upper middle income country by World Bank. Another reason for selecting these particular countries was the availability of pricing data from studies conducted in these countries using similar methodology, at HAI’s database of medicines pricing.

Latest available surveys were selected for comparison. We evaluated the affordability of 12 originator brands in private sector of Pakistan and compared these with private sector of other middle-income countries i.e. India, China, Egypt, Lebanon, using the WHO/HAI medicine prices database –. It was found that the treatment for asthma, salbutamol inhaler, was more affordable in Egypt (0.3) compared to Pakistan (0.4) and other selected countries.

Likewise, for hypertension, captopril was more affordable for patients in Egypt (0.8) and China (0.6) compared to Pakistan (1.0). Insulin Isophane (NPH) and Insulin Neutral Soluble (Regular) were less affordable in Egypt (0.8) and even in upper middle-income country, i-e., China (1.1) in comparison to Pakistan (1.4). Affordability of majority of the medicines was comparable between India and Pakistan, nevertheless, the number of daily wages needed to get the standard treatment with originator brand of Simvastatin was found to be two times higher in Pakistan compared to India and Lebanon ,. But the number of daily wages spent on obtaining standard treatment with Omeprazole were almost three times higher in Pakistan compared to China. This data suggested that ulcer treatment remained non-affordable to a vast majority of the population in Pakistan, despite its growing prevalence.

Overall, Lebanon was found to be the most affordable country in terms of obtaining standard treatment with selected medicines followed by India and Pakistan at second and third positions, respectively. The ranking has been done on the basis of average no. Of days’ wages required to get the standard treatment with selected medicines. The lesser no. Of days’ wages required, the more affordable would be the treatment in a particular country. However, possibly due to small sampling, the differences appeared trivial.

Study limitationsThe data on availability of medicines was collected at a specific point in time, thus may not reflect the average availability of medicines over the time. For sampling, district wise sampling of health facilities cannot be opted uniformly to ensure random selection, since not all districts had desired availability of tertiary and primary care health facilities, such as Lahore and Nankana sahib. Thus, sampling had to be relied upon available health facilities in each district. The affordability was estimated considering government lowest daily wage worker’s salary that might represent an over-estimation of affordability, since many private workers earn less than government daily wage worker. Moreover, except for a nationwide study conducted in 2004, not a single recent study was available from Pakistan particularly from Lahore division to compare the results of our study. Thus, the generalizability of the data to the whole country is questionable. ConclusionData revealed that in Lahore Division, Pakistan, the availability of OB medicines was extremely poor in public sector healthcare facilities in comparison to LPG medicines–yet the availability of both remain sub-optimal.

In private sector medicine outlets, the availability of OB medicines was better compared to LPG medicines but with fairly higher prices impacting patient’s affordability. Moreover, essential LPG medicines were found affordable if consumed as sole drug therapy option, nevertheless, they become unaffordable if drug therapy includes more than one drug.

Thus, several medicines, used in the treatment of common ailments such as hypertension, diabetes, ulcer and arthritis, were found unaffordable for majority population in Lahore Division, Pakistan. To improve the situation, key policy decisions should be implemented, such as use of generic medicines, sustainable and reliable procurement and financing, medicine price monitoring system, prevent excessive mark ups in the supply chain and continuing research into medicine pricing.

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Our analysis found that those containing psyllium are best.If those strategies don’t help and your constipation persists for two weeks or longer, you may need a medication to relieve your symptoms. A variety are available in both nonprescription and prescription options. Most people will get the help they need from inexpensive, nonprescription drugs, such as stool softeners and laxatives. Our 'Best Buy' pickTaking cost and the evidence for effectiveness and safety into account, we chose the nonprescription generic drug polyethylene glycol as our Best Buy for both temporary and chronic bouts of constipation. This medication improves constipation symptoms and is just as effective as a prescription drug called lactulose. In addition, it has a track record of being safe and well tolerated by most people.Stimulant laxatives such as senna (Ex-lax, Senokot, and generic) and bisacodyl (Correctal, Dulcolax and generic) may also be effective though they tend to cause more abdominal cramps and diarrhea.

Their potency may also decrease over time.If you’re unable to tolerate polyethylene glycol or it doesn’t improve your symptoms, talk to your doctor about other options, such as generic lactulose, linaclotide (Linzess), or lubiprostone (Amitiza). But Linzess is relatively new, so its safety profile is not fully established and both it and Amitiza are expensive prescription drugs. Our review of the evidence shows that they that may be no more effective than or lactulose. To understand how constipation develops, it helps to know how your large intestine, or colon, works. Muscles in the walls of your bowels propel the “waste” through your intestines after food is digested and the nutrients are absorbed in the small intestine.​ As this happens, water is reabsorbed, forming a solid stool.

To function optimally, the intestine needs a steady supply of bulk material—sometimes called “roughage”—to process. This gives the powerful intestinal muscles something substantial to propel through the system and also keeps the stool soft by holding onto intestinal water like a sponge.But if too much water is reabsorbed, if your diet doesn’t contain enough fiber, or the nerves or muscles in the intestinal walls are not functioning properly, the stool can become hard, dry, and difficult to pass, resulting in constipation symptoms. That usually means discomfort—excessive straining, difficulty completing a bowel movement, or having hard stools that hurt to pass. If symptoms like those go on for three months or longer, and there is no obvious cause, doctors call it “chronic constipation.” That can lead to hemorrhoids, painful tears in the lining around the anus (anal fissures), or stools that become so hard that they will not pass on their own (fecal impaction). Table 1: Factors that increase the chance of constipation Diet low in fiber.

Fiber makes stools softer, bulkier and easier to pass. Foods high in fiber include fruits, vegetables, beans, legumes, and whole grains.Pregnancy.

Constipation is a common problem for women during and after pregnancy. About half of pregnancy women experience it. Natural increases in the hormones estrogen and progesterone, as well as increased pressure on the bowels from carrying the baby can both affect regularity in passing stools.Age. Constipation is more common in older people. Slowing of the bowel functions is a natural part of aging, and because the older people are often on medications that slow the gastrointestinal tract.Changes in routine. Many people become constipated while traveling, especially when it involves time zone differences. Changes in your regular daily eating and sleeping habits, physical activity, and toilet routines while traveling can affect your metabolism and result in constipation.Medicines.

Constipation is a common side effect of many prescription and over-the-counter drugs. Some prescription drugs commonly known to cause constipation include pain killers, antidepressants, high blood pressure pills, and drugs to treat Parkinson’s Disease. Constipation can also be due a condition called pelvic floor dysfunction. That’s when muscles in the pelvis and around the anus that help you pass stools are not working the way they should; they clinch up when they should be relaxing. Generally, this condition does not respond very well to medication and is helped most by a technique called biofeedback that retrains the muscles to work properly.Occasionally going a day or two without a bowel movement is not that unusual and normally doesn’t require a visit to a doctor. There’s no established frequency of bowel movements that separates “healthy” from “unhealthy”— people vary in how often they go. If your frequency drops below three bowel movements a week, especially if that represents a change from your previous pattern, it’s time to see your doctor.

You should see a doctor if you are older than 50 or any of the following occur:. Bowel movements are less than three per week for two weeks or longer;. A feeling of abdominal bloating, cramping and discomfort;. Blood in your stools or it’s black or tarry-looking;. Pain when you have a bowel movement;. Persistent or recurring abdominal pain;. Sudden or sharp change in how often you move your bowels;.

List Of Medicine Drugs

Straining during bowel movements, or it takes a long time to have one;. Stools are hard, rocky or pellet-like;. Over-the-counter treatments have failed to relieve your symptoms. While studies of psyllium are not conclusive, they suggest it increases the frequency of bowel movements by at least one or two per week, on average, when compared with placebo.

So, don’t expect miracles. Metamucil is the best-known brand containing psyllium but there are generic versions that may be less expensive at your local pharmacy or food store. Read the ingredients list to make sure you are buying a psyllium supplement.Be careful though, because taking too much of a fiber supplement when you first start is a common mistake, and can lead to cramping, bloating, and gas.

Always start with the recommended, low dose and increase it gradually over time as needed. Some fiber supplements contain sugar, which may not be suitable for people with. Over-the-counter medicationsIf lifestyle changes and fiber supplements don’t resolve your constipation problem, it may be time to try a drug. But which one? As you saw from the list in Table 3, a variety of drugs are available.After fiber supplements, stool softeners are one possible next step in treatment. Examples are Colace and Regulan, both of which contain an active ingredient called docusate (with either sodium or calcium).

This drug helps retain water with the stool and soften it.While there aren’t any rigorous studies showing how effective stool softeners are in relieving chronic constipation, they are considered to be safe when taken as directed, and they can be useful in preventing constipation from developing when short-term use of medications, such as narcotic pain relievers after surgery, is unavoidable. So-called stimulant laxatives include such drugs as senna (sometimes called the sennosides; Ex-Lax, Senokot, other brands and generics) and bisacodyl (Correctol, Dulcolax, other brands and generics). These drugs stimulate the muscles of the intestines to move the stool along. That rapid movement, which can cause cramping, lessens water absorption and softens the stool.

These drugs can help alleviate single episodes of constipation, but they don’t help improve chronic constipation and are not recommended for long-term use (more than 7 days).One final group of laxatives is called the osmotic laxatives. The most common ones are based on either the active ingredient lactulose (various brands and generics) or polyethylene glycol (MiraLax, Glycolax, and generics). Polyethylene glycol is commonly available at pharmacies, grocery stores and other outlets without a prescription. Polyethylene glycolBetween lactulose and polyethylene glycol, the evidence points fairly strongly to polyethylene glycol as the first best bet for adults.

In the few studies that have compared the two head-to-head in adults, people taking polyethylene glycol consistently had greater improvements in their constipation symptoms. In addition, several studies that compared constipation drugs in children found polyethylene glycol effective for up to a year with fewer side effects than milk of magnesia or lactulose.Although not conclusive, some studies have suggested kids had fewer side effects when taking polyethylene glycol as well. One study, for example, found children taking lactulose had more abdominal pain, more pain when passing a stool, and more straining than those taking polyethylene glycol. However, in 2014, the FDA announced it was funding a study to determine if polyethylene glycol can trigger neurological problems in children. The FDA has received reports of children who developed obsessive compulsive disorder, seizures, tics, and other problems after taking polyethylene glycol. In some cases, the children had taken an adult dose for two years. The agency said the available data does not indicate the polyethylene glycol caused the neurological problems.

Two previous reviews of adverse event reports related to polyethylene glycol and a review of studies from 2009 to 2013 did not find an increased risk of those issues in children. Prescription medicationsThe three prescription-only medicines used to treat constipation are lactulose (Enulose, Kristalose and generic), linaclotide (Linzess) and lubiprostone (Amitiza).Amitiza and Linzess are relatively new drugs that cause the cells that line the intestines to secrete chloride, sodium and water to help soften stools. The FDA approved both to treat chronic constipation and irritable bowel syndrome (IBS) where the main symptom is constipation.AmitizaIn studies, about 45 percent of people with chronic constipation did not see any improvement after taking Amitiza, compared with about 67 percent of those who took a placebo. In one study in adults with constipation, after four weeks, Amitiza boosted the number of weekly bowel movements from one to more than five—those who took a placebo went from one to 3.5 weekly bowel movements. About 57 percent of the Amitiza group had a bowel movement within 24 hours of the first dose compared with just 37 percent of those on placebo.Most people who take Amitiza experience side effects. In one of the main studies, for example, 70 percent of people taking Amitiza experienced at least one side effect versus 50 percent taking the placebo. The most common problem was nausea and headache.

About 9 percent of patients had to stop taking Amitiza because of side effects. The drug has also been linked to a feeling of chest tightness and difficulty breathing. LinzessThe case is even weaker for Linzess. In three randomized trials, nearly 80 percent of people with chronic constipation did not get any benefit from Linzess, versus 95 percent for placebo.In addition, Linzess has only been available since 2012, so its safety profile is not fully established. It should not be used in children under the age of 18 because of concerns that it caused severe dehydration that led to death in young mice.The most common side effect of Linzess is diarrhea, especially if taken with a high fat meal.

It also should not be taken by pregnant or nursing women because high doses were toxic to both the mother and fetus in animal studies.LactuloseLactulose has been available for nearly 40 years. It helps relieve constipation by pulling water into your bowels, which softens stools. Its side effects include cramps, diarrhea, excessive or frequent bowel movements, gas, and nausea. It can also leave a bad taste in your mouth.It hasn’t been shown to cause any harm to developing fetuses in animal studies, but since no studies have been conducted in pregnant or nursing women, our medical advisers recommend that you don’t use it if you are pregnant or breastfeeding.There are several different generic versions, so it is an inexpensive medication compared with newer prescription medications, such as Amitiza and Linzess. A month’s supply will run about $40-$80, depending on dose.

People with chronic constipation and those with who have severe persistent symptoms are more likely to get a prescription medicine than people who have mild occasional constipation. Also, there are treatment preferences by age and population group. For example, parents should not give their children a laxative unless it is recommended by a doctor. And only the laxatives polyethylene glycol or lactulose should be tried, at smaller doses than those given adults. Senna and bisacodyl are not recommended for children under 6.Pregnant and nursing women should also consult their doctor before using any laxative drug.

Some laxatives can have adverse effects during pregnancy. And most are not recommended for women who are breast-feeding because they can be excreted in the milk.

Better options for pregnant women are adding more fiber to their diet, taking fiber supplements, increasing their fluid intake, and exercising. Special note about drug-induced constipationIf your constipation is linked to a drug you are taking, your doctor will most likely recommend changing to a different medication that will not have the same constipating effect or increasing your intake of fiber-rich foods first. Fiber supplements are another option but they have not been shown to help with drug-induced constipation.If dietary changes don’t help, a laxative is usually the next step.

For constipation triggered by an, some research suggests polyethylene glycol is better than lactulose, but neither drug is approved by the FDA for opioid-induced constipation and they have not been rigorously studied for treating it.As mentioned already, people who take high doses of opioid medications to control pain may be prescribed the drug Relistor or Movantik to relieve severe constipation. The drugs are quite potent, however, and can trigger the opposite problem: diarrhea. So people who take these drugs must be closely monitored. Unfortunately, very few studies have directly compared the various constipation drugs with each other.If you decide to try a fiber supplement, a psyllium-based one is the best bet; avoid the others.If you have chronic constipation, we’d recommend that you rule out both stool softeners and stimulant laxatives. Stool softeners probably won’t help you much.

Stimulant laxatives, such as bisacodyl, and senna are OK for short-term use for an occasional episode of constipation, and can help with chronic constipation, but they aren’t recommended for long-term use, or for children under the age of 6. The prices of Amitiza and Linzess are another downside. They are both expensive brand-name drugs costing more than $300 a month (see Table 5), and there have been no studies comparing them to more established constipation medicines.For those reasons, and because it is an inexpensive drug, we have chosen nonprescription polyethylene glycol (MiraLax and generic) as our Best Buy for treating constipation if your doctor and you have decided that you need to take a medicine. Generic and store-brand versions are available. It comes in powder form that is mixed with water. Note that polyethylene glycol is also available as a more expensive prescription drug. You’ll probably save money with the nonprescription version, but check with your insurance to be sure.Table 5., below, gives you a run down of the costs of the constipation drugs.

The good news is that most medicines used to treat the condition—including MiraLax—are inexpensive. Of course, the cost of these medicines depends on how often you take them. Use of all the constipation drugs varies widely. Many people only need to take one or two or a few doses a month, on an as-needed basis.

Others need to take a constipation medicine on a longer-term basis. Table 5 presents pricing of drugs that are more likely to be prescribed longer-term and those that are often recommended for short-term use. This report compares the effectiveness, safety, and cost of medicines used to treat chronic constipation.

Our evaluation of medicines used to treat constipation is primarily based on a systematic review conducted by the Oregon Health & Science University’s Drug Effectiveness Review Project (DERP) and a comprehensive review of treatments for constipation conducted by the American College of Gastroenterology. We also conducted a recent literature review (2015) to update the findings of a previous report.Consumer Reports is solely responsible for selecting the Best Buy Drugs.Prices for a drug can vary quite widely, even within a single city or town. The prices for prescription drugs in this report are national averages based on sales of the drugs in retail outlets. They reflect the retail cash price that would be paid for a month’s supply of each drug in June 2015. The prescription drug costs cited were obtained from a health-care information company, Symphony Health Solutions, which tracks sales of prescription drugs in the U.S.

Symphony Health Solutions is not involved in Consumer Reports Best Buy Drugs analysis or recommendations.Prices for nonprescription drugs were obtained from a nationwide sampling in February 2015 by Consumer Reports secret shoppers from four major chain pharmacies—CVS, Target, Walgreens, and Walmart.Consumer Reports selected the Best Buy Drugs using the following criteria. The drug (and dose) had to:■ Be approved by the FDA for treating constipation.■ Be as effective as any other constipation-relieving drug.■ Have a safety record equal to or better than other medications to treat constipation.■ Substantially lower cost for an average, 30-day supply compared to the most costly medications also meeting the other three criteria. Belsey JD, Geraint M, Dixon TA. Systematic review and meta analysis: polyethylene glycol in adults with non-organic constipation. International Journal of Clinical Practice. Doi:10.1111/j.1742-1241.2010.02397.x. Belsey J1, Greenfield S, Candy D, Geraint M.

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