In the public outlets surveyed, locally manufactured medicines (LMM) was more predominant than imported medicines (IM), but in general the mean percentage availability of all surveyed medicines in the public sector was low at 14.0% for (IM) and 47.2% for (LMM). There was a big variation in mean availability among the regions surveyed. The lowest for IMs availability was seen in Port-Sudan city (Eastern State) at 2.0% and for LMMs was seen in Wadmadni city (Gezera State) at 32.0%. Availability for IMs was highest in the Peripheral of Khartoum city (Capital State) at 29.6% and for LMMs was highest in S. Kordfan (Western state) at 62.4%. Figure 1 shows the mean availability in each survey region. For individual medicines (Table 2) shows the percentage availability of individual medicines grouped into bands. For imported drugs (IM); 10 of IMs were not found in any of 30 public outlets surveyed (0.0%), while most of IMs 19 were available in the range of (1.0%-10.0%). However; none of them available as 50.0% or above (highest available medicines were Diclofenac & Omeprazole 46.7%). For LMMs only one medicine not available in any of the surveyed public outlets (Atorvastatin + Amlodipine) while majority of them available as ≥40%. Amolodipine tabs was the highest available as locally manufactured medicine (83.3%).

Public sector patient prices for locally manufactured medicines were lowered priced than imported medicines and had a median MPR of 2.4 (n=42) while imported medicines had a median MPR of 4.99 (n=20). The median brand premium was 2.3 (meaning that, on average, IM were about 2.3 times the price of LMM). Hence patients were paying about 107% times the price of the LMM (on average) more when being dispensed as imported products in public sector.

Twenty (20) matched pairs of medicines were found for comparison between imported medicines and locally manufactured medicines equivalents. The MPRs for IMs and LMM are shown in Figure 2, which shows how much more IMs were priced compared to their LMM equivalents. Of both IM and LMM in public sector, Esomeprazole was found to be the highest median MPR (49.81 and 14.27 respectively). The regional comparison for IM showed that Khartoum Peripheral had the lowest median MPR for (1.77), while they were highest in Port-Sudan city (4.01) Table 4. The 25th and 75th percentiles were 2.84 and 8.53 respectively, indicating a larger variation across the pharmacies compared to LMM 1.52 and 4.02.

Again local manufactured medicines availability in the private outlets surveyed was higher than in the imported Medicines, with better availability in private sector than public sector. The mean availability of LMM was (63.9%) and for IM was (23.5%). Mean availability varied across the 6 regions surveyed. The lowest availability was also seen in Port-Sudan city (Eastern State) at (4.8%) and for LMMs in Wadmadni city (Gezera State) at (54.7%). Also Availability for IMs was highest in the Peripheral of Khartoum city (Capital State) at 40.0% and for LMMs was highest in S. Kordfan (Western state) at (79.5%). Figure 3 shows the mean availability in each surveyed region.

For individual medicines (Table 3) shows the percentage availability of individual medicines grouped into bands. For imported medicines (IM); 8 of IMs were not found in any of 30 private outlets surveyed (0.0%), while cluster of IMs (22 items) were available in the range of (1.0%-10.0% & 10-20%), 11 items in each range. Highest available medicines was Amolodipine tabs 81.5%. For LMMs only one medicine lowest available medicine in private outlets surveyed was Quitapine fumerate (3.7%) while majority of them available clustered in the range of (61.0-70.0%);13 items and ( 81.0%-90.0%); 12 items. Atenolol, Bisprolol fumerate, Cefixime caps were the highest available medicines as locally manufactured medicine (92.6% each).

Private sector patient prices for locally manufactured medicines were lowered priced and had a median MPR of 2.76 (n=45) than imported medicines which had a median MPR of 5.53 (n=27). The median brand premium was about 1.95 (meaning that, on average, IM were about two times the price of LMM). Hence patients were paying about 95% times the price of the LMM (on average) more when being dispensed as imported products in private sector.

Twenty seven (27) matched pairs of medicines were found for comparison between imported medicines and locally manufactured medicines equivalents. The MPRs for IMs and LMM are shown in Figure 4, which shows how much more IMs were priced compared to their LMM equivalents. Of both IM and LMM in private sector, Esomeprazole also was found to be the highest median MPR (65.01and 18.15 respectively).

The regional comparison for LMM showed that Khartoum Peripheral had the lowest median MPR for (2.11), while they were highest in the Wadmadni city (3.56). The 25th and 75th percentiles were 1.85 and 5.11 respectively. For IM; the lowest median MPR also in Khartoum Peripheral (3.48); while the highest in Khartoum central (5.34). The 25th and 75th percentiles were 2.89 and 9.3 respectively, indicating a larger variation across the pharmacies compared to LMM.

Across 20 medicines paired analysis patients paying more in private sector by 4.6% than public sector for imported medicines. However, across 42 medicines paired analysis patients paying more for locally imported medicines in private sector by 14.8 % than public sector. This percentage difference between private to public varies among regions for different paired items and it reaches up to 27.8% for imported medicines in peripheral of Khartoum and 41.5% for locally manufactured medicines in Wadmadni city Table 4.

One of the suggested pathways towards the removal of barriers to quality drugs is the development, or strengthening, of local production systems. Other objectives for industrial policy of local production: the desire to develop a local employment base; the need to increase technology transfer; the wish to become 'self sufficient' in medicines; the need to reduce reliance on imports and manage foreign exchange flow; and the desire to produce medicines for export. 14 The objective of this paper to provide insight into the availability, price and affordability of medicines in Sudan, comparing the availability and price of locally produced and imported medicines in public and private sectors in different regions in the country, through the use of the WHO/HAI medicine prices survey which allowed the measurement of medicine prices and availability in a reliable and standardized way that enables valid systemic comparisons to be made.

The survey showed low availability of the basket of medicines surveyed in the public and private sectors for imported medicines (I.M), while not achieving WHO s target of 80 % for locally manufactured medicines (LMM). In the public sector outlets, locally produced products were far more commonly stocked than imported products (47.2% compared to 14%). In the private sector, outlets tended to stock more locally produced products (63.9%) compared to imported products (23.5%). In all six survey regions the availability of locally produced products was higher than for imported products in the public and private sectors. Similar results were obtained from Ethiopian survey where locally produced medicines are more predominant than imported medicines, while opposite results were obtained from Tanzanian survey, that imported medicines are more available than locally produced medicines. 15 In developing countries particularly Sub-Saharan countries a lot of barriers are well known to business and industrial concern affecting availability and self-reliance in drug production as a mean of increasing access to medicines; such as a weak financial sector (banking/non banking); diminished availability and flows of foreign currency for investment; inflation; taxes; shortage of technical expertise; non stable supply of electricity, gas and other utilities. Also manufacturing settings activities are limited to compounding and packaging, and processing bulk medicines into dosage forms using imported raw materials; on average 40-50% of their cost of goods sold tied up to raw material costs which in turn need to be paid for in foreign exchange. Indeed, machinery, technology, quality control equipment, advertising and distribution networks must often be purchased for foreign exchange. ^{14 & 16}

The survey results show that patients are paying significantly more to purchase imported medicines than locally manufactured medicines in all sectors surveyed. While noting the WHO target that consumers should pay no more than four times the IRPs, we observed that medicine prices were higher for imported medicines compared to IRPs in both public and private sector (4.99 and 5.53 respectively). Overall patients were paying 107% more in public sector and 95% more in private sector for imported products compared to locally produced products. Some individual imported medicines were being purchased at very high prices than locally produced ones e.g. Esomeprazole 20 mg cap were dispensed as imported medicines at a price that was 3.5 times than locally produced price in both public and private sectors.

Compared to information on medicine prices and availability in general, little is known about the impact of local medicine production on prices and availability in different countries. In many countries, studies found locally produced medicines had lower patient prices compared to imports. Kuanpoth found locally produced ARVs had lower patient prices compared to imported ARVs in Vietnam. 17 Chowdury and Kabir found locally produced over-the-counter essential medicines in Bangladesh had lower patient prices compared to imports. 18 Sweileh et al. found lower patient prices for antibiotics made locally compared to imports. 19 One study, conducted by Shafie and Hassali in Malaysia, found some locally produced generics had higher patient prices compared to imports. 20

The apparent consumer willingness to pay higher prices for imported products, as seen in the public and private sector in Sudan, may reflect a perception that imports are of higher quality. To boost local industries, the government needs to ensure and publicise the equivalent quality of locally produced medicines, also the local pharmaceuticals need to spend more money in promotion and marketing of their products and do not depends only on price difference from imported medicines. Supporting local manufacturers through fiscal and/or non-fiscal incentives must be time-bound, developed and implemented in a transparent way, and should not be implemented suddenly or abruptly otherwise it may unintended had a negative effects on the availability. Balancing local production policies is critically important and information on foreign exchange, exports, imports, job demand and other economic and societal indicators need to be evaluated before and after creating local manufacturing capacity; and before and after changes in industrial and/or pharmaceutical policy with regard to local production of pharmaceuticals.

Finally; In-spite of all obstacles facing local production we have to recognize that many advantages of local production for both public health and economic development could be achieved such as improve affordability of quality medicines from known and frequently inspected facilities. It has also the potential to offer other advantages over imports; for example by shortening related supply chains; it can help reduce stock outs and by expanding and diversifying the supply chain, it allows developing countries to secure access in response to growing demands. There is also some evidence that locally manufactured products are more successful in reaching rural populations than imported ones.

Strategic and logistic limitations in our research may have affected the findings . Thus, three main limitations arose, firstly; we did not include the procurement sector, and identifying prices and availability of imported and locally produced medicines procured by the government, secondly we were not differentiate between prices and availability of imported medicines by product type (originator brands, branded generics) and thirdly; patient affordability have not been measured furthermore, price components in the supply chain.