Drugs for STD management in developing countries: choice, procurement, cost, and financing.

OBJECTIVES: (i) To compare acquisition costs of drugs between countries to treat one standardised STD episode. (ii) To explain variations, treatment protocols, purchasing policies, procurement systems, and sources of financing.

METHODS: National STD guidelines, purchasing mechanisms, and drug acquisition costs from 15 countries were compiled, using information from ministries of health and European Commissions headquarters. Prices were converted in European currency unit (ecu). Acquisition costs per episode were calculated for the four main STD syndromes--urethral discharge, vaginal discharge, lower abdominal pain in women, and genital ulcer disease (GUD). To compare costs in different countries the relative distribution of the four main STD syndromes was calculated.

RESULTS: Treatment protocols. All 15 countries recommended treatment for urethral discharge with drugs effective against Neisseria gonorrhoeae and Chlamydia trachomatis. For vaginal discharge two patterns emerged. In 11 countries women with vaginal discharge were divided into high risk of STDs and low risk of STDs. Women at low risk were treated for candidiasis, trichomoniasis, and bacterial vaginosis and those at high risk were also treated for N gonorrhoeae and C trachomatis. Guidelines for abdominal pain all included treatment for N gonorrhoeae, C trachomatis, and anaerobic infections. All countries except the Philippines recommended treating GUD with drugs effective against chancroid and syphilis. Costs per episode. Acquisition costs per episode varied from 0.40 ecu to 7.89 ecu with wide variations. The standardised acquisition cost of STD drugs for the public sector varied between 0.54 ecu in Tanzania and 5.80 ecu in Swaziland. The choice of drugs was the main factor explaining this difference. In countries which only use generic drugs, acquisition costs were lower (between 0.54 ecu and 1.07 ecu). However, important variations exist between countries which use similar treatment protocols (for example, 2.54 ecu in Namibia, 5.80 ecu in Swaziland). These variations are mainly explained by differences in procurement methods. Acquisition costs for peripheral public services are higher than at central level (for example, 0.89 ecu versus 0.54 ecu in Tanzania) as a result of mark ups for transport, handling, and inflation. Acquisition cost of drugs per standardised STD episode for patients through private pharmacies may be as high as 11.93 ecu in Senegal. This is more than 10 times the acquisition cost for public sector at central level in this country (of 1.04 ecu) and is mainly due to the fact that drugs in private pharmacies are branded drugs, which are imported at a high price, taxes, and mark ups in the distribution chain. In 11 of the 15 countries studied, effective STD drugs are now available through public services, in at least in a part of the country. In Botswana, Ghana, Ivory Coast, Mauritania, Lesotho, Namibia, Senegal, Seychelles, and Swaziland these drugs are supplied throughout the country within the existing essential drug programme and financed by the government budget or through a revolving fund for drugs. In Tanzania and Mozambique, all STD drugs in the public sector are funded through donor support. In Nepal recommended STD drugs are widely available at low cost through private outlets.

CONCLUSIONS: Reducing antimicrobial susceptibility of N gonorrhoeae and Haemophilus ducreyi is a continuous threat for sustainable STD drug supply as alternative patented drugs are more expensive. If patented STD drugs are required drug cost may be minimised by selecting the most appropriate management protocols and by improving procurement. Moreover, recent studies have confirmed the continued susceptibility of N gonorrhoeae to low cost generic drugs in some countries (Mozambique, Tanzania, and Senegal). Even under these circumstances, continued donor support will be needed for the poorest countries to ensure the availability of effective STD management as an esse