title: Prices and mark-ups on antimalarials: evidence from nationally representative studies in six malaria-endemic countries.
abstract: The private for-profit sector is an important source of treatment for malaria. However, private patients face high prices for the recommended treatment for uncomplicated malaria, artemisinin combination therapies (ACTs), which makes them more likely to receive cheaper, less effective non-artemisinin therapies (nATs). This study seeks to better understand consumer antimalarial prices by documenting and exploring the pricing behaviour of retailers and wholesalers. Using data collected in 2009-10, we present survey estimates of antimalarial retail prices, and wholesale- and retail-level price mark-ups from six countries (Benin, Cambodia, the Democratic Republic of Congo, Nigeria, Uganda and Zambia), along with qualitative findings on factors affecting pricing decisions. Retail prices were lowest for nATs, followed by ACTs and artemisinin monotherapies (AMTs). Retailers applied the highest percentage mark-ups on nATs (range: 40% in Nigeria to 100% in Cambodia and Zambia), whereas mark-ups on ACTs (range: 22% in Nigeria to 71% in Zambia) and AMTs (range: 22% in Nigeria to 50% in Uganda) were similar in magnitude, but lower than those applied to nATs. Wholesale mark-ups were generally lower than those at retail level, and were similar across antimalarial categories in most countries. When setting prices wholesalers and retailers commonly considered supplier prices, prevailing market prices, product availability, product characteristics and the costs related to transporting goods, staff salaries and maintaining a property. Price discounts were regularly used to encourage sales and were sometimes used by wholesalers to reward long-term customers. Pricing constraints existed only in Benin where wholesaler and retailer mark-ups are regulated; however, unlicensed drug vendors based in open-air markets did not adhere to the pricing regime. These findings indicate that mark-ups on antimalarials are reasonable. Therefore, improving ACT affordability would be most readily achieved by interventions that reduce commodity prices for retailers, such as ACT subsidies, pooled purchasing mechanisms and cost-effective strategies to increase the distribution coverage area of wholesalers.
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK, benjamin.palafox@lshtm.ac.uk.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Palafox
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Edith
authors.initials: E
authors.lastname: Patouillard
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Tougher
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Goodman
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Immo
authors.initials: I
authors.lastname: Kleinschmidt
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Sergio
authors.initials: S
authors.lastname: Torres Rueda
authors.affiliation: Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.
authors.forename: Sabine
authors.initials: S
authors.lastname: Kiefer
authors.affiliation: Population Services International, Malaria & Child Survival Department, PO Box 43640, Nairobi, Kenya.
authors.forename: Kate
authors.initials: K
authors.lastname: O'Connell
authors.affiliation: Association Béninoise pour le Marketing Social/PSI, BP 08-0876, Tri Postal, Cotonou, Benin.
authors.forename: Cyprien
authors.initials: C
authors.lastname: Zinsou
authors.affiliation: Population Services International Cambodia, No 29 St. 334, PO Box 153, BKK1 Chamcar Mon, Phnom Penh, Kingdom of Cambodia.
authors.forename: Sochea
authors.initials: S
authors.lastname: Phok
authors.affiliation: Association de Santé Familiale, 4630 Avenue de la Science, Immeuble USTC, Bloc C, Gombé, Kinshasa, Democratic Republic of Congo.
authors.forename: Louis
authors.initials: L
authors.lastname: Akulayi
authors.affiliation: Society for Family Health, 8 Port Harcourt Crescent, Area 11 Garki, Abuja, Nigeria.
authors.forename: Ekundayo
authors.initials: E
authors.lastname: Arogundade
authors.affiliation: Programme for Accessible Health, Communication and Education, Plot 2 Ibis Vale, PO Box 27659, Kololo, Kampala, Uganda and.
authors.forename: Peter
authors.initials: P
authors.lastname: Buyungo
authors.affiliation: Society for Family Health, Plot No 549, Ridgeway, PO Box 50770, Lusaka, Zambia.
authors.forename: Felton
authors.initials: F
authors.lastname: Mpasela
authors.affiliation: Population Services International, Malaria & Child Survival Department, PO Box 43640, Nairobi, Kenya.
authors.forename: Stephen
authors.initials: S
authors.lastname: Poyer
authors.affiliation: Population Services International, Malaria & Child Survival Department, PO Box 43640, Nairobi, Kenya.
authors.forename: Desmond
authors.initials: D
authors.lastname: Chavasse
mesh_terms: D000349:Africa; D000962:Antimalarials / Q000191:economics* / Q000627:therapeutic use; D037621:Artemisinins / Q000191:economics / Q000627:therapeutic use; D002160:Cambodia; D003132:Commerce / Q000191:economics*; D004345:Drug Industry / Q000191:economics; D004359:Drug Therapy, Combination; D014943:Global Health; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D008288:Malaria / Q000188:drug therapy; D017149:Private Sector / Q000191:economics*; D011795:Surveys and Questionnaires
chemical_list: D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin
keywords: Antimalarials; malaria treatment; pharmaceutical pricing; private sector