Antivenom for sale? Availability and affordability of snakebite medicines across public and private health facilities in Rwanda

Abstract

Antivenom is considered the safest and most effective treatment against snake envenomation (SBE); however, global shortages mean that many low-income countries struggle to meet demand. In Rwanda, chronic shortages of essential medicines are an important barrier to robust healthcare delivery and discourage snakebite victims from seeking hospital care. The aim of this retrospective, cross-sectional study was to evaluate the availability and affordability of commodities to treat SBE at hospitals and health centers. In total, our team interviewed pharmacy managers at 111 public and 31 private health facilities (N = 142) to complete a validated quantitative questionnaire, entering data electronically through KoBoCollect. Commodity prices were collected in 2023RWF and for the lowest cost item across any category. A commodity was considered affordable if a treatment regimen cost less than one day's wages, using the international poverty line to approximate a low-income worker's wages. Across all health facilities, mean availability of SBE commodities was relatively good (77.1%). Snake antivenom was only available at public hospitals and was concentrated in urban rather than rural areas. Two snake antivenom types were observed, one of which was not appropriate for treating envenomation by East African snakes. Overall, this meant that only 4.2% of facilities stocked safe and effective antivenom. Black stones, an ineffective traditional treatment, were sold by 5.6% of health providers. Moreover, antivenom did not meet the minimum threshold for affordability, costing on average 10 days of work for a single dose among uninsured individuals. Altogether, this study highlights serious performance gaps among pharmacies responsible for procuring and supplying SBE commodities and helps to explain the widespread belief that SBE treatment is unaffordable at hospitals and health centers. Urgent action is needed to ensure that all hospital and health center pharmacies located in high-risk areas stock appropriate antivenom and that re-stocking time for essential medicines is reduced.