A spatial analysis to evaluate the impact of deregulation policies in the pharmacy sector: Evidence from the case of Navarre

Contracting retail pharmacies as a source of essential medicines for public sector clients in low- and middle-income countries: a scoping review of key considerations, challenges, and opportunities

BACKGROUND

Insurances in high-income countries (HIC) often contract with private community pharmacies to dispense medicines to outpatients. In contrast, dispensing of medicines in low- and middle-income countries (LMICs) often lacks such contractual arrangements. Furthermore, many LMICs lack sufficient investment in supply chains and financial and human resources to guarantee stock levels and services at public medicine-dispensing institutions. Countries striving to achieve universal health coverage (UHC) can, in principle, incorporate retail pharmacies into their supply chains to expand access to essential medicines (EMs). The objectives of this paper are (a) to identify and analyze key considerations, opportunities and challenges for public payers when contracting out the supply and dispensing of medicines to retail pharmacies and (b) to provide examples of strategies and policies to address these challenges.

METHODS

A targeted literature strategy was used to conduct this scoping review. We created an analytical framework of key dimensions: (1) governance (including medicine and pharmacy regulation); (2) contracting (3) reimbursement; (4) medicine affordability (5) equitable access; and (6) quality of care (including 'patient-centered' pharmaceutical care). Using this framework, we selected a mix of three HIC and four LMIC case studies and analyzed the opportunities and challenges encountered when contracting retail pharmacies.

RESULTS

From this analysis, we identified a set of opportunities and challenges that should be considered by public payers considering public-private contracting: (1) balancing business viability with medicine affordability; (2) incentivizing equitable access to medicines; (3) ensuring quality of care and delivery of services; (4) ensuring product quality; (5) task-sharing from primary care providers to pharmacies and (6) securing human resources and related capacity constraints to ensure sustainability of the contract.

CONCLUSION

Public-private partnerships offer opportunities to improve access to EMs. Nonetheless, managing these agreements is complex and is influenced by a variety of factors. For effective contractual partnerships, a systems approach is needed in which business, industry and regulatory contexts are considered in tandem with the health system. Special attention should be devoted to rapidly changing health contexts and systems, such as changes in patient preferences and market developments brought about by the COVID-19 pandemic.

A quantitative classification of OTC medicines regulations in 30 European countries: dispensing restrictions, distribution, pharmacy ownership, and pricing systems

BACKGROUND

This paper reviews the regulations of over-the-counter (OTC) medicines in 30 European countries with the goal of identifying the regulatory trends and clusters as of May 2022.

METHODS

To that end, we reviewed the regulation that directly or indirectly might have an impact on OTC medicines. The data were gathered from the national legislation, reports from international organizations, and the existent literature. The 12 regulatory items obtained were classified into four categories: price, pharmacy ownership, distribution modes, and dispensing restrictions. In addition, these items were also employed in the cluster analysis.

RESULTS

Pharmacy ownership is mainly private, and in the majority of countries, OTC medicines are not subject to any pricing system. Almost every country studied allows online selling of OTC medicines, and 16 countries allow non-pharmacy retail to sell OTC medicines as well. The dispensing restrictions applicable in pharmacy retail are similar in the countries studied: they rely on the staff, OTC medicines are placed behind the counter and the doses dispensed tend to be restricted. Concerning non-pharmacy retail, additional dispensing restrictions might be imposed, such as the establishment of buyers' minimum age, the requirement of a pharmacist to supervise the operations, a regulation on the location in the store, and further restrictions on the package sizes, strength, or pharmaceutical form. The cluster analysis resulted in an initial division between countries that widely allow the sale of OTC medicines in non-pharmacy retail and countries, where pharmacy retail has an OTC monopoly. Based on the regulations, 7 subsequent groups were identified evidencing wide regulatory heterogeneity within the countries studied.

CONCLUSIONS

Our findings point out that OTC medicines are in general not subject to pricing systems, selling is allowed online, and ownership of pharmacies is mostly private. However, regarding dispensing restrictions, pharmacy chains, and establishment restrictions of pharmacies, we found heterogeneity that is also visible in our cluster analysis, since we identified 7 clusters.

Application and utility of geographic information systems in pharmacy specific health research: A scoping review

BACKGROUND

Geographic Information Systems (GIS) are considered essential tools to analyze spatially referenced health data.

OBJECTIVES

The purpose of this scoping review is to describe how GIS is used in pharmacy specific health research.

METHODS

During July 2020, the following databases were searched: EMBASE, MEDLINE (PubMed), Web of Science and Scopus. The search strategy included terms relating to spatial analysis and pharmacy. Studies were considered eligible if they involved the use of GIS and focused on pharmacies. A narrative and tabular synthesis of the results was carried out, structured around the spatial analysis methods utilized across studies, as well as the characteristics of pharmacies evaluated in studies.

RESULTS

After a review of 6967 sources, 48 studies were included in this review. Twenty-nine studies were conducted in the United States (60.4%) and thirty-six focused on accessibility (75.0%; n = 36). Twenty-two studies investigated the relationship between sociodemographic aspects of the population and the accessibility and availability of pharmacies (45.8%). Twelve studies (25.0%) performed distance analysis and six studies (12.5%) performed geostatistical analysis. Community pharmacies were the setting evaluated most frequently, with over-the-counter selling products being the most evaluated pharmacy variable (13.3%; n = 6). Population density (58.3%; n = 28), income indicators (43.8%; n = 21) and minority community composition rates (41.7%; n = 20) were the most used population variables.

CONCLUSIONS

GIS have been increasingly used in pharmacy specific health research. Generally, research has sought to identify potential barriers to access and their effects on the population. Future research may benefit by utilizing robust spatial methods and applications across countries outside of the United States. Doing so could help to confirm the impact of sociodemographic characteristics on the availability and/or accessibility of pharmacies globally.

Geographical accessibility to upper secondary education: an Italian regional case study

In this paper, a spatial analysis is performed to measure students' access to the upper secondary education system. Based on the definition of quantitative indicators, the adopted approach is applied to an Italian regional case by exploiting the capabilities of a GIS software and using census tracts' level data. The obtained results highlight geographical patterns of inequalities in access among students and shed light on the least served areas. Further analysis shows that accessibility reflects the degree of urbanization within the study region and that geographical distances are actual barriers to rural students since they are not compensated for by either economic status or the availability of digital infrastructures. The study offers empirical grounds to inform the decision-making process toward equity-in-access oriented interventions. Longer-term actions, as the activation of new schools (network expansion), the activation of new programs (service expansion) or the redistribution of their supply among the current network (network reorganization), as well as mid-term ones, like offering economic support for students' mobility, or reinforcing digital connectivity, emerge as relevant to mitigate social exclusion.

A Spatio-Temporal Analysis of the Health Situation in Poland Based on Functional Discriminant Coordinates

The aim of this study was to investigate if the provinces of Poland are homogeneous in terms of the observed spatio-temporal data characterizing the health situation of their inhabitants. The health situation is understood as a set of selected factors influencing inhabitants' health and the healthcare system in their area of residence. So far, studies concerning the health situation of selected territorial units have been based on data relating to a specific year rather than longer periods. The task of assessing province homogeneity was carried out in two stages. In stage one, the original spatio-temporal data space (space of multivariate time series) was transformed into a functional discriminant coordinates space. The resulting functional discriminant coordinates are synthetic measures of the health situation of inhabitants of particular provinces. These measures contain complete information regarding 8 diagnostic variables examined over a period of 6 years. In the second stage, the Ward method, commonly used in cluster analysis, was applied in order to identify groups of homogeneous provinces in the space of functional discriminant coordinates. Sixteen provinces were divided into four clusters. The homogeneity of the clusters was confirmed by the multivariate functional coefficient of variation.

To evaluate the impact of opening up ownership of pharmacies in South Africa

Background

Following the democratic elections in 1994 the South African private pharmaceutical services were mostly in metropolitan centred with a scattering of pharmacies in less densely populated areas. The Government introduced regulations relating to the ownership and licensing of pharmacies on the 25th of April 2003 to improve access to pharmaceutical services by removing ownership restriction to only pharmacists.

Objective

To assess the outcomes of the policy implementation in improving access to pharmacies.

Method

The register of pharmacies at the South African Pharmacy Council was analysed from 1994 to 2014. Each registration was assigned GPS coordinates using Q-GIS(V3.6) and mapped per province at a district level, following clean-up and verification of the register. New registrations were also categorised as either corporate or independent pharmacy. Population census was obtained from Statistics South Africa and used to determine the number of pharmacies per 100,000 population.

Main outcome measure(s)

Number of active pharmacies; Number of independent pharmacies; number of pharmacies in each district.

Results

The number of active pharmacies increased from 1624 at the end of 2003 to 3021 by 2014. The closure rate decreased from 137 to 86 pharmacies per year post regulations, a 37.23% reduction with a net gain of approximately 127 pharmacies per year. About 38.30% of all pre-2003 pharmacies (622 of 1624) closed by 2014. The population increase in the study period was approximately 20.66% but the overall growth of pharmacies was only 1.88 pharmacies per 100,000 population (3.55 to 5.43). Following the regulations in 2004, 23.9% of pharmacies active within the system closed between 2004 and 2014, of which, 91.7% of them were independent pharmacies.

Conclusion

Opening up of pharmacy ownership in South Africa increased the number of pharmacies in the country but did not result in increased access in previously less populated areas. There was still clustering of pharmacies in a well resourced areas, with a steady growth in corporate pharmacy (35%) ownership.

The 2017 deregulation of pharmacies in Italy: Introducing non-pharmacist ownership

Italy is the last European country to adopt policies on the liberalization of pharmacy ownership. In August 2017, the Italian government approved the law n. 124 (annual market and competition law), despite the opposition of some stakeholders. This law extended the ownership of pharmacies to non-pharmacist business partners. Law n. 124 is an important turning point for pharmacists in Italy and could lead to a general reorganization of the Italian pharmaceutical system. As has already happened in several European countries, the removal of barriers to pharmacy ownership incentivizes finance companies and pharmaceutical wholesalers to make significant investments in this sector, leading to the emergence of commercial pharmacy chains. The future of community pharmacies is uncertain and is closely linked to the fate of the current government. However, progressive polarization between independent pharmacies and pharmacies that are part of chains can already be observed.