1.         Generic production. The presence or absence of generic competition in the open market is a key determinant of pricing levels. Competition brings down prices dramatically. For example, fluconazole is not patented in Thailand. Before fluconazole was produced as a generic in 1998, Pfizer sold it for US$7 per 200mg capsule. Then, three Thai companies began production and Pfizer dropped its price to US$3.6, even though generic companies were charging much less (Biolab was charging US$0.6).
After initially responding to generic competition, Pfizer increased its price in Thailand to US$6.2 in March 2000, while Biolab’s price decreased its price to US$0.3 (20.7 times cheaper than Pfizer’s price). Multinational 20 companies have had to contend with similar competition from CIPLA in India. Glaxo Welcome’s lamivudine (3TC) 150mg tablet costs 78 percent less in India than in the United States. Brazil generically manufactures a great deal of its ARV drug supply, which is sold at a fraction of the price globally. A generic form of zidovudine is 14 times cheaper in Brazil than in the United States (Per├ęz-Casas and Boulet, 2000a).
2.         Cost-drivers, tariffs, and taxation. In addition to multinational monopoly pricing regimes, costs within a country make essential drugs even more out of reach for Nigerians. The executive secretary of the Nigerian Pharmaceutical Group, Kunle Okelola, noted that the following add-ons create substantially higher drug costs:
A.        Shipping and handling usually is about 20—30 percent of the drug price.
B.        Additional costs exist for shipping to health facilities (inland transportation cost).
C.        Taxes paid on imported drugs are 25 percent.
D.        Imported raw materials are 5 percent.
E.         There should be no value-added tax (VAT) on pharmaceuticals; however, some are still made to pay 5 percent (a cost that is now in the process of being eliminated).
F.         Prices are marked up by manufacturers, importers, suppliers, and retailers to ensure profits for everyone.
G.        There is no excise duty on locally made products (Ikoro, 2001).
3.         Differential pricing: Comparing prices between countries is inherently difficult because of the problem of comparing official exchange rates and real currency values; differences in pharmaceutical distribution channels (private versus public sector, retail versus wholesale); different strengths and pharmaceutical dosages; price fluctuations overtime, and so forth. However, companies often price the same drugs in different countries at different prices.  (UNICEF et al., 2000)

1.         Challenges of availability of affordable laboratory-monitoring tests and trained manpower required for the implementation of HIV therapy
Few laboratories in resource-constrained countries can afford to perform laboratory- monitoring tests required for the implementation of HIV therapy. Flow cytometric techniques are expensive and require a significant infrastructure to perform. In addition, the measurement of quantities of virus in the blood known as viral load is an important clinical parameter to evaluate the severity of disease and to monitor the efficacy of therapy. These expensive laboratory tests require complex technologies not previously used in much of the developing world. Scientists are devising new methodologies that they hope will be as sensitive as existing methodologies yet more cost effective. The laboratory infrastructure is the most expensive and specialized part of any institutional framework for HIV/ AIDS cares (Stephenson, 2002). In Nigeria, policymakers and decision makers have tended to view laboratories in the narrow context of HIV screening. At the onset of the ART program no laboratory in the country had the full capacity needed to monitor treatment response and toxicity properly. Only a handful of institutions had the capacity to perform CD4+ counts, a necessary test for decision-making in HIV therapy. The federal government program provided the training and technical capacity for CD4+ tests to be performed in the 25 treatment centers using a manual microscopic technique, This technology is labour intensive, and one laboratory scientist cannot reliably perform more than 10 tests a day. This pace cannot accommodate the expansion of ART in these centers and in other centers that would rely on them for laboratory support. Through a generous donation from MTN Nigeria, a telecommunications company, APIN was able to equip two federal treatment centers—at University College Hospital and Jos University Teaching Hospital—with flowcytometry—based instruments (Imade et al., 2005), which allow technicians to process more than 100 CD4÷ tests daily. The instruments cut the cost of the tests four- to fivefold. All Harvard PEPFAR program sites are now equipped with these instruments. Many other programs in Nigeria, particularly the other PEPFAR programs, have opted for that investment as well. Similarly, when the ART program started in Nigeria, only one centre had the capacity to perform viral load tests routinely; these tests are used to measure the virus level in the blood of infected individuals and thereby allow clinicians to assess treatment efficacy. This centre, the Nigerian Institute of Medical Research, had been upgraded and equipped by a grant from the Ford Foundation. APIN, a project based at the Harvard School of Public Health (HSPH) and sponsore1d by the Bill & M1inda Gates (Stephenson et al., 2002)
2. Challenges of deciding the optimal time to start antiretroviral treatment
Highly Active Antiretroviral Therapy (HAART) has changed the landscape of HIV- related care in the developed world with marked reduction in mortality and morbidity (Cameron et al., 1998). This possibility however is beyond the reach of a vast majority of HIV-infected in sub Saharan Africa. Following the development of HAART, many physicians were quite aggressive in treating patients at virtually any stage of this human retroviral disease. Increasing concern related to drug toxicities, pill burden, cost and ability of patients to adhere to strict and complicated regimens, have complicated the decision-making process for physicians and patients alike (Volberding, 2000). Despite promised price-reduction and increased availability of generic drugs in some countries, cost remains a major factor in deciding when to start therapy.
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