Chronic Diseases, the Silent Killers – For years, all we do is feed. We don’t control what our parents feed us for dinner, we don’t control what they read to us (or don’t read to us) or what they let us watch. We are like jars of wet clay, and we are loaded full with every kind of tale – films; books; TV shows; stories from friends, parents, grandparents. And as we dry, we take the shape of what has been dumped inside of us.”
The impact of our early beginnings on our health cannot be underestimated. Decades ago infectious disease were the leading causes of death and by and large have maintained their status to date. However thanks to a widening of the middle classes and relatively increased affluence, chronic diseases have become lethal too. The likes of hypertension, diabetes, angina, cancers etc. are common reasons given for death of many over forties in Ghana.
In other countries chronic disease are attenuated and not major causes of death. The main stay of their management is early diagnosis, drug management based on concordance, routine checks and lifestyle modification. Truth is strict adherence to these cost money in our part of the world.
For any medicine to be effective, it has to be taken at the right dose, right time, for the right period, right cost and the right contraindications respected. This requires that the patient is convinced and agrees with the prescriber and pharmacist that these R’s are respected. This agreement is what is termed concordance. In short chronic disease management is a joint approach; with cost of medicines a major fulcrum.
Truth is most prescribers want the best for their patients but would prescribe on the basis of affordability and accessibility. Though Ghana has a national health insurance scheme, most new medicines for the management of chronic diseases are excluded from the list. The reason for their exclusion is often high cost and availability of much older cheaper alternatives. This leaves the patient with only one option, “if you want state of the art medicines with relatively minimal side effects, pay for the privilege.” In short increase life expectancy is auctioned to the highest bidder.
Studies suggest that poor adherence to hypertension treatment is responsible for about two-thirds of uncontrolled hypertension, leading to complications such as stroke. Therefore any factor that results in noncompliance is a potential killer. A look at the national drug expenditure makes interesting reading; total expenditure on health in Ghana is about $12 per capita with 50% ($6) of this being out of pocket. The current health budget is about $6.50 per capita, compared to $10 per capita in 1978, a drop of 35% over approximately 40 years.
In contrast the prices of new medicines on the global market have increased thanks to the high cost of research and development by about 54% over a similar period. Hence the landed cost of medicines locally especially those used in the management of chronic diseases is high. The matter is further complicated by the low critical mass of patients willing to pay premium for their health, when many of these chronic diseases are asymptomatic and silent till they strike. A look at the 2014 Ghana Demographic and Health Survey indicates that 13% of both women and men age 15-49 had hypertension. The majority of those with hypertension had only mildly elevated blood pressure. Among the oldest respondents aged 45-49, 38% of women and 24% of men had elevated blood pressure. Truth is 1 in 2 of all adults over 40 in Ghana has a form of chronic disease; sadly many do little or nothing about it; primary reason being affordability.
From a demographic stand point, the percentage of Ghanaians over the age of 40 is approximately 20% (5 million people). This estimates to approximately 2.5 million people over this age affected by a chronic disease. Of this number available data indicates that 70% are unable to purchase high end newer medicines and rely on the NHIS, with only 12.5% purchasing chronic disease medicines on a regular month by month basis. Thus the retail pharmacy sector is left with about three hundred thousand Ghanaians across ten regions to make provision for. This is a very small number to provide leverage and purchasing power. In short many of our large wholesalers get only marginal discounts and rebates on imported newer medicines.
In the world of retail pharmacy there is a sacred rule, “NEVER LOCK YOUR CAPITAL IN HIGH END, SLOW MOVING MEDICINES.” This results in supply chain issues for patients on such medicines. On the other hand with a mark-up on wholesale prices of between 30% and 60% at many retail outlets, many patients are paying through the nose just to stay alive. The pricing is further complicated by the fluctuating Cedi. The average monthly wholesale cost of chronic disease medicines generally used in Ghana is between $4.5 and $25 monthly. This is on the assumption that the patient takes up to three different medicines. At the beginning of 2015 this equated to GHC14.85 to GHC82.5. As at today the average local wholesale cost is GHC17.15 to GHC95.25, an appreciation of 15.5%. This percentage has been passed straight on to the patient and further indexed with about 45% mark-up.
One fact we all have to take cognisance of is, “pharmaceutical retail and the sale of high end medicines is no charity but a profit making venture.” In short retail prices of chronic disease medicines have gone up by about 61% over a ten month period. The real truth is that the major contributors to these astronomical increases do not lie in the domain of pharmacy but are underpinned by the poor economic strength of our country. Often many pharmacies especially those outside Accra and Kumasi opt not to stock these medicines as they lock capital and eventually expire, leading to massive capital loss. Pharmacies have gone bankrupt from targeting the high end of the market in an attempt to improve standards, maintain supply chain consistency and ensure quality in a country where these are alien concept.
In return other pharmacy owners have learnt how painful it is to see start-ups crumble in a manner so eloquently depicted by William Manchee in Go Broke, Die Rich: Turning Around the Troubled Small Business. “There are few experiences in life as painful and brutal as the failure of a small business. For a small business conceived and nurtured by its owner is like a living, breathing child. Its loss is no less traumatic than losing a loved one.” Raise your hand if you can afford to see your living breathing child die.
I will conclude by saying the upward march of out of pocket medicinal cost, especially those used in chronic disease management locally is here to stay. We can cry our eyes out for all we care with little or no impact; the will to correct the fundamentals is badly missing.