Essential medicines for universal health coverage

Access to mifepristone, misoprostol, and contraceptive medicines in eight countries in the Eastern Mediterranean Region: descriptive analyses of country-level assessments

BACKGROUND

Despite their importance in reducing maternal mortality, information on access to Mifepristone, Misoprostol, and contraceptive medicines in the Eastern Mediterranean Region is limited.

METHODS

A standardized assessment tool measuring access to Mifepristone, Misoprostol, and contraceptive medicines included in the WHO essential medicines list (EML) was implemented in eight countries in the Eastern Mediterranean Region (Afghanistan, Iraq, Lebanon, Libya, Morocco, Palestine, Pakistan, and Somalia) between 2020-2021. The assessment focused on five access measures: 1) the inclusion of medicines in national family planning guidelines; 2) inclusion of medicines in comprehensive abortion care guidelines; 3) inclusion of medicines on national essential medicines lists; 4) medicines registration; and 5) procurement and forecasting of Mifepristone, Misoprostol, and contraceptive medicines. A descriptive analysis of findings from these eight national assessments was conducted.

RESULTS

Only Lebanon and Pakistan included all 12 contraceptives that are enlisted in the WHO-EML within their national family planning guidelines. Only Afghanistan and Lebanon included mifepristone and mifepristone-misoprostol combination in post-abortion care guidelines, but these medicines were not included in their national EMLs. Libya and Somalia lacked a national regulatory authority for medicines registration. Most contraceptives included on the national EMLs for Lebanon, Morocco and Pakistan were registered. Misoprostol was included on the EMLs-and registered-in six countries (Afghanistan, Iraq, Lebanon, Morocco, Palestine, and Pakistan). However, only three countries procured misoprostol (Iraq, Morocco, and Somalia).

CONCLUSION

These findings can guide efforts aimed at improving the availability of Mifepristone, Misoprostol, and contraceptive medicines in the Eastern Mediterranean Region. Opportunities include expanding national EMLs to include more options for Mifepristone, Misoprostol, and contraceptive medicines and strengthening the registration and procurement systems to ensure these medicines' availability were permitted under national law and where culturally acceptable.

Towards greater impact in health technology assessment: System dynamic approach for new and emerging technologies in Iran

PURPOSE

As classical health technology assessment models fail to predict the complexities of related impacts, the application of modeling techniques such as systems dynamics simulation (SD) is essential. This study aimed to develop an SD model to predict the outcomes of access to a new medicine in Iran.

METHODS

This study extracted the important and influential variables in providing access to new pharmaceutical technologies by comprehensively reviewing previous research and combining the technical knowledge of experts in this field. The variables were incorporated into the systems thinking framework and modeled using dynamic systems tools, followed by simulation and testing in VENSIM. The model was piloted for deferoxamine and deferasirox in thalassemia. Various tests were used to evaluate the validity and reliability of the model. The model was designed for a ten-year horizon (2018-2028) for medicines selected as the pilot.

RESULTS

The variables extracted from the panel of experts encompassed the primary and short-term impacts of access to newly emerged medicine and long-term impacts regarding the economy, health, and society. After modeling, the leverage points presented for the problem with the greatest impact or effectiveness in access to new medicine included the policy determining the amount of medicine supply, the import and production of medicine, the prevalence and incidence of disease, insurance coverage, and treatment adherence.

CONCLUSION

The SD models allow the researchers to evaluate the efficiency and health outcomes of a new pharmaceutical more precisely in the health system in Iran.

Sustainability challenges concerning the effects of high-priced drugs on the day-to-day operations of community pharmacies in Finland

BACKGROUND

High-priced drugs pose a challenge for health budgets, policies, and patient safety. One of the key roles of community pharmacies is to ensure availability to prescription drugs regardless of their price. This has been identified as challenging in certain situations concerning high-priced drugs.

OBJECTIVES

The aim is to investigate the views of proprietary pharmacists regarding the effects of high-priced drugs on the day-to-day operations of pharmacies.

METHODS

The data collection of the study was performed as a national cross-sectional online survey. The inclusion criteria were being a proprietary pharmacist and a member of the Association of Finnish Pharmacies. The survey contained questions yielding both quantitative and qualitative answers. The study focused on the qualitative data which was analysed by deductive thematic analysis.

RESULTS

In total 604 proprietary pharmacists were sent the survey, and 174 eligible answers were included in the study, giving a response rate of 29%. The result describes the relationships between the economic, social, and environmental dimensions of sustainable development based on a framework by Wanamaker, with respect to high-priced drugs and community pharmacy operations as viewed by proprietary pharmacists. The main findings of the study show that proprietary pharmacists find the implementation of real-time reimbursement payments, a further reform of the pharmacy tax, and the abolishment of return bans to the wholesaler as risk mitigations and means to attain sustainability with respect to high-priced drugs and pharmacy practice. They experience that these changes would diminish high-priced drugs unnecessarily ending up as medical waste and improve the working conditions of the pharmacy staff by alleviating stress.

CONCLUSIONS

According to the respondents, high-priced drugs pose challenges for community pharmacies and the legislation and reimbursement system need to adapt to these challenges. If not, community pharmacies in Finland continue to face severe financial declines based on the study results.

Procurement process and shortages of essential medicines in public health facilities: A qualitative study from Nepal

Ensuring access to essential medicines remains a formidable challenge in Nepal. The specific reasons for the shortage of essential medicines within Nepal have not been extensively investigated. This study addresses challenges associated with access to essential medicines, procurement process difficulties, and functionality of inventory management systems at different levels of public health facilities. Fifty-nine semi-structured in-depth interviews were conducted with health managers and service providers at provincial and local levels in six randomly selected districts of Bagmati province, Nepal. Interviews were audiotaped and transcribed verbatim, and the results were analyzed using the inductive approach and were later mapped within the four domains of "Procurement of essential medicines". The major barriers for the effective management of essential medicines included delays in the procurement process, primarily locally, leading to frequent stock-out of essential drugs, particularly at the health post level. Additionally, challenges arise from storage problems, mainly due to insufficient storage space and the need to manage additional comorbidities related to COVID-19. Other identified challenges encompass the absence of training on logistics management information systems, a lack of information technology resources in primary health facilities, inadequate qualified human resources to operate the IT system, and insufficient power backup. Moreover, unrealistic demand estimation from the service points, inadequate transportation costs, and manual inventory management systems further contributed to the complex landscape of challenges. This study identified procurement delays as the primary cause of essential medicine shortages in Bagmati Province, Nepal. We recommend implementing comprehensive procurement guidelines, collaborative training, and dedicated budgets to address this issue. Improving the procurement and inventory management process in low-resource settings requires a well-trained workforce, suitable storage spaces, and enhanced coordinated administrative tiers within health facilities at different levels to ensure the year-round availability of essential medicines in these settings.

Innovations in pharmaceutical policies and learnings for sustainable access to affordable medicines

Sustainable access to affordable medicines remains a public health issue globally, including for high-income countries. To foster the debate on avenues for the future, the fifth PPRI Conference held in Vienna on 25 and 26 April 2024 will offer a forum for the debate on innovating pharmaceutical policymaking to develop and implement futureproof policy options, which are able to address current and future challenges. The Conference invites a broad audience of stakeholders, including researchers, policymakers, payers, patients, industry and health professionals. The conference topics are organised in three strands: Strand 1 on 'Local challenges, global learnings' aims to contribute to lively discussions on the implementation of pharmaceutical policies across the globe. Best-practice examples will be presented, supplemented by case studies of less effective policies which can offer rich learnings. Strand 2 on 'Strengthening the evidence base' is the place for presentations and discussions on topics such as health technology assessments, managed entry agreements and real-world data. Strand 3 'Futureproofing pharmaceutical policies' is particularly dedicated to explore innovation in policymaking to achieve sustainable access to affordable medicines.

Global Barriers to Accessing Off-Patent Endocrine Therapies: A Renaissance of the Orphan Disease?

CONTEXT

Clinical endocrinology encompasses many diseases requiring long-term drug therapy. Prohibitive pricing of some endocrine drugs classified as essential by the World Health Organization has created suboptimal care of patients with endocrine disorders.

EVIDENCE ACQUISITION

This review is based on evidence obtained from several databases and search engines including PubMed, Google, and Google Scholar; reference searches; manual searching for web pages of international regulatory bodies; and the authors' experience from different healthcare settings.

EVIDENCE SYNTHESIS

After the expiry of a patent, generic versions with the opportunity for increased availability and a price reduction are expected. There are access barriers worldwide for many off-patent endocrine drugs. The high price is the main issue for several medicines including insulin, hydrocortisone, testosterone, and gonadotropins. This is caused by several factors including the market monopoly due to the lack of registered generics or suppliers limiting the benefit of competition and a complex supply chain. Additionally, the lack of some medicines has been concerning due to market factors such as the relatively small number of patients, making it less attractive for the manufacturers. Commissioning of nonprofit manufacturers and state manufacturing as well as strict price control measures could alleviate this situation.

CONCLUSION

Lack of availability and disproportionate price inflation affecting essential off-patent endocrine therapies is common due to several interrelated factors. Global collaboration among healthcare organizations with the support of policymaking bodies might be needed to mitigate this.

Cancer control collaborations between China and African countries

Over the past decade, China has emerged as Africa's largest trade partner and source of foreign direct investment, with public health ranked as a top priority in China-Africa collaborations. During the same period, cancer has emerged as a leading cause of death in Africa, with more than 700 000 deaths per year and projections of more than 1 million deaths per year by 2030. In this Review, we explore the effects of increasing China-Africa collaborations on cancer control in Africa. We review the published literature on health-care assistance, research, education and training, and infrastructure and present the results of an institutional review board-approved survey of African oncology health-care professionals and institutional leaders that assessed their perception of the effects of China-Africa collaborations. From peer-reviewed articles and grey literature, we found that the number of China-Africa collaborations have grown substantially over the past decade in different areas, especially in patient care and infrastructure. Research publications have also surged in quantity in the past decade compared with previous years. However, the survey results suggest research collaborations remain infrequent and that medical professionals in African cancer centres rarely participate in direct research collaborations with Chinese institutions. The Review also highlights the challenges and benefits of increasing China-Africa collaborations. Challenges include insufficient monitoring and evaluation of the projects in Africa and poor coordination and alignment of the various initiatives. The benefits of these collaborations for Africa include improved health outcomes, strengthened health systems, and socioeconomic development. Benefits are also apparent for China, such as securing energy and resource supplies, expanded trade and investment opportunities, and improved diplomatic relations. Overall, China-Africa collaborations are increasing and having a substantial effect in both China and the African continent. Recommendations to minimise the challenges and maximise the benefits for more positive consequences on cancer control in Africa are discussed.

Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review

BACKGROUND

The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use).

METHODS

We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted.

RESULTS

From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy.

CONCLUSION

Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.

Quality Assessment of Selected Essential Antimicrobial Drugs from Drug Retail Outlets of Selected Cities in Eastern Ethiopia

The prevalence of substandard and falsified (SF) antimicrobial drugs is increasing around the globe. This poses a great concern for the healthcare system. The consumption of SF antimicrobial drugs has the potential to result in treatment failure, emergence and development of antimicrobial resistance, and ultimately a rise in mortality rate. The objective of this study was to assess the quality of four commonly used antimicrobials marketed in the cities of Dire Dawa and Jijiga and the town of Togo-Wuchale, which have high potential for illegal drug trade activities in Ethiopia because they are located near the border with Somalia. A total of 54 brands/samples of amoxicillin, amoxicillin/clavulanic acid, ciprofloxacin, and norfloxacin formulations were collected covertly from 43 facilities using a convenience sampling strategy from March 16 to March 29, 2022. The samples were first screened using Global Pharma Health Fund (GPHF)-Minilab protocols and then analyzed using U.S. Pharmacopoeial and British Pharmacopoeia official methods. The quality evaluation detected no falsified product; however, it showed that 14.3% of the samples failed the GPHF-Minilab screening test semiquantitatively. Overall, 22.2% of the products analyzed did not meet any of pharmacopoeial specifications assessed: 13%, 12.2%, and 11.1% of the products failed in assay, dissolution, and weight variation, respectively. Additionally, 56.3% of amoxicillin samples, 60% of amoxicillin/clavulanate, 20% of ciprofloxacin, and 54.5% of norfloxacin samples were found to be pharmaceutically nonequivalent with their respective comparator products regarding dissolution profiles. The study showed the presence of substandard antimicrobial medicines in the eastern Ethiopian market.

Challenges associated with the availability, accessibility, and use of antivenoms for treating snakebite envenoming in Ghana: A MaxDiff experiment design

Successful snakebite envenoming (SBE) treatment requires safe, effective, and quality-assured antivenom products specifically tailored to combat endemic venomous snake species. This study aims to identify the challenges associated with the availability, accessibility, and use of antivenoms for treating SBE. The data for this study were obtained from a cross-sectional study involving healthcare workers from two districts (namely Afram Plains North and Afram Plains South) in the Eastern Region of Ghana. Through the MaxDiff design methodology, we quantify the challenges associated with the availability, accessibility, and use of antivenoms. Responses from a simple random sample of 203 healthcare workers were included in this study. Participants identified the high cost of antivenoms as the most challenging factor that limits the availability, accessibility, and use of antivenoms for treating SBE. Other important challenges were the lack of access to effective antivenoms in remote areas when needed and the increased use of unorthodox and harmful practices, followed by resort to unorthodox and harmful practices and the lack of effective antivenoms to address envenoming from local species in some instances. However, poor outcomes from using substandard antivenoms, stock-outs, inadequate number of manufacturers, and the resort to substandard, cheap, and harmful antivenoms were traded off. Also, poor utilization of antivenoms, suboptimal utilization of antivenoms (low quality, under-dose), use of ineffective, substandard antivenoms, and flooding of the market with products that have not been evaluated thoroughly were underscored. Our findings provide essential data to guide discussions on barriers to the availability, accessibility, and use of antivenoms for treating SBE to improve the supply of antivenoms, enhance the effectiveness of snakebite treatment, and improve patient care quality in Ghana. Multi-component strategies are needed to address the challenges identified, such as intensified advocacy, ongoing education and community engagement, healthcare worker training, and leveraging institutional and governance structures.

User-experience testing of an evidence-to-decision framework for selecting essential medicines

Essential medicine lists (EMLs) are important medicine prioritization tools used by the World Health Organization (WHO) EML and over 130 countries. The criteria used by WHO's Expert Committee on the Selection and Use of Essential Medicines has parallels to the GRADE Evidence-to-Decision (EtD) frameworks. In this study, we explored the EtD frameworks and a visual abstract as adjunctive tools to strengthen the integrate evidence and improve the transparency of decisions of EML applications. We conducted user-experience testing interviews of key EML stakeholders using Morville's honeycomb model. Interviews explored multifaceted dimensions (e.g., usability) on two EML applications for the 2021 WHO EML-long-acting insulin analogues for diabetes and immune checkpoint inhibitors for lung cancer. Using a pre-determined coding framework and thematic analysis we iteratively improved both the EtD framework and the visual abstract. We coded the transcripts of 17 interviews with 13 respondents in 103 locations of the interview texts across all dimensions of the user-experience honeycomb. Respondents felt the EtD framework and visual abstract presented complementary useful and findable adjuncts to the traditional EML application. They felt this would increase transparency and efficiency in evidence assessed by EML committees. As EtD frameworks are also used in health practice guidelines, including those by the WHO, respondents articulated that the adoption of the EtD by EML applications represents a tangible mechanism to align EMLs and guidelines, decrease duplication of work and improve coordination. Improvements were made to clarify instructions for the EtD and visual abstract, and to refine the design and content included. 'Availability' was added as an additional criterion for EML applications to highlight this criterion in alignment with WHO EML criteria. EtD frameworks and visual abstracts present additional important tools to communicate evidence and support decision-criteria in EML applications, which have global health impact. Access to essential medicines is important for achieving universal health coverage, and the development of essential medicine lists should be as evidence-based and trustworthy as possible.

Uptake of orphan drugs in the WHO essential medicines lists

Objective

We evaluated the uptake of medicines licensed as orphan drugs by the United States Food and Drug Administration (FDA) or European Medicines Agency (EMA) into the WHO Model list of essential medicines and the WHO Model list of essential medicines for children from 1977 to 2021.

Methods

We collated and analysed data on drug characteristics, reasons for adding or rejecting medicines, and time between regulatory approval and inclusion in the lists. We compared trends in listing orphan drugs before and after revisions to the inclusion criteria of the essential medicines lists in 2001, as well as differences in trends for listing orphan and non-orphan drugs, respectively.

Findings

The proportion of orphan drugs in the essential medicines lists increased from 1.9% (4/208) in 1977 to 14.6% (70/478) in 2021. While orphan drugs for communicable diseases have remained stable over time, we observed a considerable shift towards more orphan drugs for noncommunicable diseases, particularly for cancer. The median period for inclusion in the essential medicines lists after either FDA or EMA first approval was 13.5 years (range: 1-28 years). Limited clinical evidence base and uncertainty about the magnitude of net benefit were the most frequent reasons to reject proposals to add new orphan drugs to the essential medicines lists.

Conclusion

Despite lack of a global definition of rare diseases, the essential medicines lists have broadened their scope to include medicines for rare conditions. However, the high costs of many listed orphan drugs pose accessibility and reimbursement challenges in resource-constrained settings.

Improving access to medicines to reduce marketing and use of substandard and falsified medicines in Africa: Scoping review

Background

Both constrained access to essential medicines and combatting marketing of substandard and falsified (SF) medicines are unmet health sector goals in Africa.

Objective

To answer the question of how improved access can reduce the continuous surge of SF medicines in Africa.

Design

We conducted a scoping review based on standard protocol.

Methods

We searched articles published in the English language from PubMed/Medline, Cochrane Library, Embase, Scopus, Web of Science, and Google Scholar by using a systematic search query.

Results

Seventy-one articles were included in this review. Access to quality essential medicines is still a major problem in developing countries in Africa and will continue as a threat for the next decade of health care. Ensuring access to quality medicines and preventing SF medicines in Africa need a systematic approach to address their underlying causes. Failure to ensure access to medicines is the major reason for the availability of SF medicines. Improving access to quality medicines can reduce SF medicine marketing and use. Manipulating the entire supply chain for efficiency, avoiding trade agreements that could reduce access, using compulsory licensing provisions, and pharmaceutical price control, providing incentives for drug development, and promoting rational use of medicines can improve access.

Conclusion

Ensuring access to medicines and preventing SF medicine marketing cannot be achieved in the planned period in developing countries in Africa unless a comprehensive strategy is used. Improving access to quality medicines can reduce SF medicine marketing and use, that is, ensuring access through uninterrupted supply, improved efficiency, enhanced local production, preventing SF medicine entry, improved medication use system, and improved affordability. Therefore, it is essential to improve supply chain capability, address challenges of the supply chain, improve leadership and governance, establish country-specific anti-counterfeiting and anti-substandardization committees, and collaborate with all relevant stakeholders.

Performance of Jazia Prime Vendor System in ensuring availability of health commodities in Singida Region, Tanzania: a pre- and post-evaluation study

BACKGROUND

Availability of the health commodities in public health facilities in Tanzania remains a challenge, and has been reported to be below 70%. Moreover, Medical Stores Department's capacity to supply health commodities has been only 40%. Therefore, Jazia Prime Vendor System (Jazia PVS) was outsourced to complement the Medical Stores Department. In 2017 Jazia PVS was introduced in Singida Region after being piloted in three other Regions. This study therefore, was conducted to assess the performance of Jazia PVS in enhancing the availability of the health commodities in the public health facilities between 2017 and 2019 in Singida Region, Tanzania.

METHODS

A mixed method pre- and post-evaluation analytical study design was used in all the selected public health facilities in the Municipal and District Councils of Singida Region, Tanzania. These included 138 public health facilities: One Regional Referral Hospital, four District Hospitals, 19 Health Centres and 114 Dispensaries. Percent availability of health commodities was abstracted from electronic logistics management information system. Documentary review involved quarterly orders, Jazia PVS delivery notes, and payment vouchers; while all the 138 pharmacists incharge were interviewed.

RESULTS

The mean availability of health commodities was modestly higher after adoption of Jazia PVS (mean = 59.17%, SD = 6.12%) than before Jazia PVS (mean = 54.39%, SD = 5.36%); and the difference between means was 4.78% (t = -9.49, df = 136, p < 0.001). Furthermore, 20.3% (109/421) of orders were fulfilled, while 58% (312/421) were not, (χ2 = 10.46, df = 6, p = 0.1067). About 73.7% of orders (320/434) were delivered on time, while 26.3% (114/434) delayed, (χ2 = 121, df = 6, p < 0,001). Prompt payment to Jazia PVS was 43.0% (164/381) deliveries, while 57.0% (217/382) were not punctual, (χ2 = 26, df = 6, p < 0.001). Satisfaction level of the pharmacists incharge for Jazia PVS was 11.8%, (χ2 = 78.04, df = 3, p < 0.001).

CONCLUSION

With Jazia PVS, availability of health commodities improved by 4.78% in 2 years. Prompt payment of Jazia PVS will enhance performance of the vendor.

A desktop review of evaluation of implementation of national medicines policies in SADC countries

A national medicine policy (NMP), formerly referred to as a national drug policy (NDP) is a document that serves as a political commitment and guide for action by the government to provide safe, efficacious, quality assured, available, affordable and rationally used medicines. This is the first study to review the implemented components of the NMPs of the 16 South African Development Community (SADC) countries over the past ten years (2011-2021). Information published between 2011 and 2021 of each country such as pharmaceutical profiles, official government documents, WHO/HAI/World Bank datasets and research studies on the implemented components were appraised. Significant progress has been made by 16 SADC countries over the period 2011-2021 in implementing the NMP. The most commonly implemented components included the concept of essential medicines, pricing, and regulation. Though traditional and herbal medicines component is yet to be implemented by the majority. The pharmacist-patient ratio of 1:2300 was below the target for all countries, prompting the need to strengthen the pharmacy personnel in the healthcare systems. Medicine pricing, affordability, and availability studies are necessary to develop equitable pricing policies that will improve the accessibility of medicines in all countries and the SADC region. With the exception of the Republic of Tanzania, SADC countries need to urgently revise their NMPs, thus adopting progressive processes such as incorporating Health Technology Assessment (HTA) in the NMP. All SADC countries require a strong, internationalistic evaluation culture built-in their policy formulation. As the first study to investigate the implemented NMPs in the SADC region, it could serve as a springboard for the countries to address their common pharmaceutical challenges thus improving their readiness for universal health coverage (UHC). Future in-depth cross-country studies in the SADC region are necessary to comprehensively evaluate the implemented components of NMPs.

Predictors of medicine redistribution at public healthcare facilities in King Cetshwayo District, KwaZulu-Natal, South Africa

BACKGROUND

Effective pharmaceutical inventory management is essential for optimizing healthcare outcomes and supply chain performance. However, challenges such as stockouts, overstocking, and wastage can hinder this process. This study examines the interrelationships between overstocking, stockouts, and wastage in eight healthcare facilities in Northern KwaZulu-Natal, South Africa. It also explores the extent of these challenges and investigates the use of medicine redistribution as a strategy to address inventory management issues.

METHODS

A retrospective quantitative analysis was conducted using pharmacy inventory records from public healthcare facilities. Eight facilities, including hospitals and a community healthcare center in King Cetshwayo District, were purposively sampled. Linear regression analysis was used to examine the association between medicine redistribution as the outcome and the predictors - stockouts, overstocking, and wastage. Pearson's correlation was utilized to evaluate associations between the predictors. Descriptive statistics were employed to quantify the levels and extent of overstocking, stockouts, and wastage related to expiry.

RESULTS

The study included eight healthcare facilities with pharmacy warehouses managed by pharmacists. A total of 392 medicines were analyzed (49 per facility). Stockouts affected 85.6% of medicines, while overstocking and expiry-related wastage impacted 50.6% and 15.2% of medicines, respectively. The most common stock-out medicines were salbutamol 200mcg inhalant (4.0%), paracetamol 500 mg tablets (3.5%), and azithromycin 500 mg tablets (3.3%). Overstocking, stock with short-dated expiry, and expired medicines explained 68% of redistribution transactions to other facilities (r² = 0.68). A moderate, statistically significant correlation was observed between overstocking and expiry-related wastage (r² = 0.47, p-value = 0.020). Stockouts had a weak correlation with redistribution, accounting for only 4.5% (p-value < 0.01). A weak correlation was found between stockouts and overstocking (r = 0.10), as well as between stockouts and expired medicines (r = -0.20).

CONCLUSION

This study highlights significant challenges in inventory management, particularly regarding stockouts, overstocking, and expiry-related wastage in the evaluated healthcare facilities. Medicine redistribution emerged as a viable strategy to address these challenges. Improving inventory management practices and implementing targeted interventions are crucial for optimizing pharmaceutical supply chain performance and enhancing healthcare delivery outcomes in this setting.

Accessibility crisis of essential medicines at Sudanese primary healthcare facilities: a cross-sectional drugs' dispensaries assessment and patients' perspectives

BACKGROUND

Access to essential medicines is a critical component of universal health coverage. However, the availability of essential medicines in Sudan isn't well studied. As well, most Sudanese people lack health insurance, making out-of-pocket spending the primary source of drug financing. Therefore, the affordability of medicines in Sudan is questionable, with only 30% of the total population being covered by a public health service or public health insurance. We undertook this study to assess the availability and prices of essential medicines in public-sector health facilities in Khartoum state. Moreover, this study aims at assessing patients' perceived affordability of essential medicines, and accommodation and acceptability of the public facility.

METHODS

A cross-sectional study was carried out at 30 primary healthcare facilities' drug dispensaries across three districts in Khartoum state. Within each Centre's dispensary unit, a standardized checklist evaluated the availability and affordability of 21 essential medicines selected from Sudan's national essential medicines list and assessed their storage conditions. Furthermore, 630 patients were selected from all dispensary units for an exit interview that assessed their perceived accessibility, acceptability, accommodation, and affordability of essential medicines. Data were collected through the Kobo toolbox and analyzed using SPSS version 26.

RESULTS

Participants' ratings of accessibility, affordability, accommodation, and acceptability were 3.7/5, 1.5/4, 5/6, and 5.4/6, respectively, with a 26.7% full access and weak correlation between some of the indices. The overall availability of adults and pediatric medicines was 36.8% 6.7%, respectively. Cost of a single course of treatment for 10 and 16 drugs out of the 19 drugs consumed exceeds the daily wage of insured and uninsured patients, with a median price ratio of 16.4 and 62.8, respectively. Moreover, the dispensary area conditions were found to be of good quality, yet the storerooms were not functioning in 40% of the outlets.

CONCLUSION

Patients had limited access to their needed drugs due to high prices and physical unavailability, and primary healthcare capacities are not meeting the demands of citizens. The outcomes for the patients' access variables (accessibility, accommodation, acceptance, and affordability) are comparable to those in countries with low incomes. Ensuring access to free medicines is likely to improve patients' satisfaction with healthcare services and reduce private expenditure on medicines, which is a long-term, sustainable way towards universal health coverage in Sudan.

Access and use of WHO essential medicines in Italy

Background

Many countries use the WHO Essential Medicines List (EML) as a guide for health policy choices to promote the efficient use of healthcare resources or adopt the concept of essential medicines (EMs) to develop their own national list of essential medicines. The aim of this study is to analyse the availability and use of medicines included in the 22nd WHO EML in Italy.

Methods

Using the ATC code (5th level), a comparison was made between the medicines included in the WHO EML and those retrieved from the Italian Medicines Agency (AIFA) database. The availability (regulatory and reimbursement status) of EMs, as well as the market share in expenditure (million euros) and consumption [measured in WHO-defined daily doses (DDDs)], compared to all reimbursed medicines in 2021, were analysed.

Results

In 2021, approximately 85.2% (n = 414) of medicines included in the WHO EML were commonly marketed in Italy. Of these, 396 EMs were fully reimbursed by the Italian National Healthcare Service (INHS), corresponding to 81.5% (396/486) of the WHO EML, while the remaining 18.5% (90/486) were neither authorised (n = 72) nor reimbursed (n = 18). The study found a low coverage for anti-parasitic, insecticides, and repellent products (ATC P) in addition to medicines for the genitourinary system and sex hormones (ATC G). Even though medicines on the WHO EML, including therapeutic alternatives, accounted for ~48.5% of the expenditure for medicines reimbursed by INHS, the list covered 74% of all national drug consumed. Novel high-cost therapies indicated in high-prevalence diseases and rare conditions, mostly antineoplastic and immune-modulating agents (ATC L) not included in the WHO EML, were also guaranteed.

Conclusions

In Italy, high coverage of EMs was found. It was largely reimbursed by the INHS, even when compared to other European countries. Essential medicines represented a high percentage of the overall expenditure and consumption in Italy. The WHO EML could be an important tool to guide the health policy choices of high-income countries, although a more frequent update and easier access to information on rejected medicines are needed.

Registration of essential medicines in Kenya, Tanzania and Uganda: a retrospective analysis

OBJECTIVES

To audit national drug registers (NDRs) in Kenya, United Republic of Tanzania and Uganda with respect to national Essential Medicine Lists (EMLs) and to conduct an analysis of highly registered products including a sub-analysis of highly registered antimicrobial products.

DESIGN

Retrospective analysis of registration of essential medicines and medicinal products on NDRs as of February 2018.

SETTING

Not applicable.

PARTICIPANTS

None.

MAIN OUTCOME MEASURES

Registration status of essential medicines by country, essential medicine status of registered products by country and medicines with more than 50 registrations across all three countries.

RESULTS

A high proportion of essential medicines are not registered: Kenya 28% (175/632), United Republic of Tanzania 50% (400/797) and Uganda 40% (266/663). Of registered products on the NDRs, more than half are not essential: Kenya 71% (4350/6151), United Republic of Tanzania 64% (2278/3590) and Uganda 58% (2268/3896). When the three NDRs were combined, there were 42 medicines with over 50 registered products, accounting for 30% (4153/13637) of products, many of which were non-essential.

CONCLUSIONS

Non-registration of essential medicines is a barrier to availability. Over-registration of medicines, particularly non-essential medicines, diverts regulatory resources towards registering non-priority and, sometimes, clinically sub-optimal medicines. The East African Community Medicines Registration Harmonization Project has the potential to improve access to key medicines if registration of essential medicines is prioritised and registration of non-essential medicines is restricted.

Challenges and Strategies for Improving Access to Cancer Drugs in Malaysia: Summary of Opinions Expressed at the 2nd MACR International Scientific Conference 2022

Considerable progress has been made in cancer drug development in recent decades. However, for people in low- and middle-income countries, including Malaysia, many of these drugs are not readily available. During the 2nd Malaysian Association for Cancer Research (MACR) International Scientific Conference, a forum discussion was held to address these challenges and explore strategies to improve access to cancer medicines in the country. This paper presents the results of the said forum discussion. A few challenges to cancer drug access were highlighted, including lengthy approval and regulatory practices, cost of medicines, and manufacturing barriers. Besides, a few strategies for mitigating some of these challenges were proposed, such as mechanisms for cost reduction, uptake of biosimilars and generics, local manufacturing, public-private partnerships, strengthening the role of insurance companies, funding and regulation, and advocacy for fair pricing, by drawing examples from cancer medicines access initiatives in Malaysia and initiatives for different disease groups. Overall, this paper provides a comprehensive overview of the challenges and strategies for improving access to cancer medicines in Malaysia and provides valuable insights for policymakers, healthcare providers, the pharmaceutical industry, cancer patients, cancer support groups, and other stakeholders working on this important issue.

How and why pharmaceutical reforms contribute to universal health coverage through improving equitable access to medicines: a case of Ghana

Background

Examining how and why a country prioritizes and implements pharmaceutical reforms tends to show complex processes and myriad efforts made toward improving access to medicines. This study examines factors that enabled the prioritization and implementation of selected pharmaceutical reform items and how these factors contributed to improving equitable access to medicines and universal health coverage in Ghana.

Methods

An analytical framework was developed to identify variables to explore in answering the study questions and frame the analysis and presentation of findings. Documents analyzed included the National Medicines Policies, Health Sector Program of Work, and other health policies. Quantitative data were sourced from databases maintained by World Health Organization and the Institute for Health Metrics and Evaluation.

Results

The three main factors, evidence, financial and technical support, and alignment to national and global policies, influenced the prioritization and implementation of access to medicines reforms. The reforms targeted rational selection and use of medicines, medicine pricing, sustainable medicine financing, and regulatory and supply chain systems. Although there were limited quantitative data to quantify access to medicine policies" impact on universal health coverage, it can be reasonably assumed that, in Ghana, access to medicine policies has contributed to financial protection and improved access to quality health services.

Conclusion

Access to medicine policies targeted at promoting rational medicine selection and use, regulating medicine pricing and improving sustainable financing for medicines as well as the regulatory and supply chain systems arguably contributed to the attainment of UHC and must be sustained. Therefore, data collection and reporting indicators for access to medicines must be prioritized.

Biosimilars and interchangeable biosimilars: facts every prescriber, payor, and patient should know. Insulins perspective

INTRODUCTION

For many of the 537 million adults living now with diabetes, the cost of insulin is becoming prohibitive as the insulin prices have tripled between 2002-2013. Globally, the direct annual cost of healthcare expenditure due to diabetes will soon be US$1 Trillion. Biosimilars provide access to high-quality, affordable biologic therapy that is otherwise inaccessible due to the high costs of original biologics.

AREAS COVERED

A primer to the development of biosimilars shows comparable structural and analytical characterization to the original biologics (e.g. insulins), with no clinically significant or meaningful differences in efficacy and safety. 'Interchangeability' status, a regulatory designation by the US FDA, bestowed to some biosimilars, enables confidence in high-quality, bio-equivalent biosimilar of insulin with key global approvals. This can allow rapid uptake of biosimilars by the prescribers, formulary decision-makers, and payors. Biocon-Viatris's biosimilar Insulin Glargine (Semglee®) is the first interchangeable biosimilar insulin approved by the US FDA.

EXPERT OPINION

The 'interchangeable' status can prompt faster and wider uptake of insulin biosimilars and keep the insulin expenditure under control, especially for patients who otherwise practice non-adherence or rationing of life-saving insulin. Education, support, and awareness can ensure that interchangeable biosimilars gain wider acceptance.

Challenges to the Availability and Affordability of Essential Medicines in African Countries: A Scoping Review

Introduction

The availability and affordability of safe, effective, accessible, and high-quality essential medicines is a critical benchmark for achieving the right to good health, and it is also one of the goals of the global health development agenda. To that end, it is critical to conduct rigorous studies to identify the major challenges confronting developing countries, particularly those in Africa.

Objective

The purpose of this review was to identify the major challenges that Africans face in obtaining reasonably priced and readily available essential medicines.

Methods

Generally the Boolean operators "AND" and "OR" were employed. Making progress also involves using duplicate checks, field definitions, and comparisons of articles and criteria. The analysis included all English-language papers published in any African country between 2005 and 2022, depending on the year of publication. The technique searches electronic databases for key phrases related to essential medication availability and affordability, such as PubMed, Web of Science, Scopus, Science Direct, Plos Medicine, and Google Scholar.

Results

A total of 91 articles; by using search engines and handpicking including duplicates, were primarily searched. The electronic database search earned 78 articles while only eleven studies met the criteria for review and were reviewed of which 5 (50%) were from East African countries. Inadequate human resources, financial constraints, high cost of available medications on the market, poor inventory management, manual consumption forecasting, inefficiencies in drug registration, and trade-related aspects of intellectual property rights agreement regulations are all obstacles to the availability of essential medicines in African nations.

Conclusion

This review revealed that in Africa, the availability and affordability of essential medicines face numerous challenges. The primary challenge, according to the review research, is a lack of adequate financing to pay for an appropriate set of essential medications, which account for a significant portion of household spending.

Expert Recommendations for the Diagnosis, Treatment, and Management of Adult B-Cell Acute Lymphoblastic Leukemia in Latin America

PURPOSE

Despite strong induction chemotherapy response rates, only 30%-40% of patients with adult B-cell acute lymphoblastic leukemia (ALL) attain long-term remission. This study analyzes ALL in Latin America (LA) and recommends diagnosis, treatment, and management protocols.

METHODS

The Americas Health Foundation organized a panel of hematologists from Argentina, Brazil, Chile, Colombia, and Mexico to examine ALL diagnosis and therapy and produce recommendations.

RESULTS

Lack of regional data, unequal access to diagnosis and therapy, inadequate treatment response, and uneven health care distribution complicate adult ALL management. The panel recommended diagnosis, first-line and refractory treatment, and post-transplantation maintenance. Targeted treatments, including rituximab, blinatumomab, and inotuzumab ozogamicin, are becoming available in LA and must be equitably accessed.

CONCLUSION

This review adapts global information on treating ALL to LA. Governments, the medical community, society, academia, industry, and patient advocates must work together to improve policies.

When should global health actors prioritise more uncertain interventions?

Global health actors use economic evaluations, including cost-effectiveness analyses, to estimate the effect of different interventions they might fund. However, producing reliable cost-effectiveness estimates is difficult, meaning organisations must often choose between funding interventions for which reliable predictions of efficacy exist and those for which they do not. In practice, many organisations appear to be risk-averse, favouring more certain interventions simply because they are more certain. We argue that this practice is not justifiable. Prioritising projects backed by greater evidence might often produce greater health benefits. However, a general tendency to prefer more certain interventions will cause global health actors to overlook opportunities to help less well-studied populations, support promising but complex interventions, address the upstream causes of illness, and conduct the most important impact evaluations. We argue that global health actors should instead adopt nuanced attitudes towards uncertainty and be willing to fund highly uncertain interventions in some cases. We further describe the considerations they should take into account in rendering these judgements.

Attention-deficit/hyperactivity disorder medication consumption in 64 countries and regions from 2015 to 2019: a longitudinal study

Background

Timely recognition and appropriate treatment of attention-deficit/hyperactivity disorder (ADHD) are essential to enhance long-term outcomes of individuals with ADHD. This study aimed to evaluate the multinational trends and patterns of ADHD medication consumption.

Methods

In this longitudinal trend study, we used pharmaceutical sales data of ADHD medication from the IQVIA-Multinational Integrated Data Analysis System between 2015 and 2019, covering 64 countries across the world. Consumption rates of ADHD medication were expressed as defined daily dose per 1000 child and adolescent inhabitants (aged 5-19) per day (DDD/TID). Linear mixed models were used to estimate the multinational, regional, and income level trend changes.

Findings

The results showed that multinational ADHD medication consumption increased by +9.72% (95% confidence interval [CI], +6.25%, +13.31%) per year, from 1.19 DDD/TID in 2015 to 1.43 DDD/TID in 2019 across the 64 countries with marked differences between geographical locations. When stratified by countries' income levels, increases in ADHD medication consumption were observed in high-income countries but not in middle-income countries. In 2019, the pooled consumption rates of ADHD medication were 6.39 DDD/TID (95% CI, 4.63, 8.84) in high-income countries, 0.37 DDD/TID (95% CI, 0.23, 0.58) in upper-middle-income countries and 0.02 DDD/TID (95% CI, 0.01, 0.05) in lower-middle-income countries.

Interpretation

Current ADHD prevalence estimates and rates of ADHD medication consumption in most middle-income countries are lower than the global epidemiological prevalence. It is therefore imperative to evaluate the potential barriers to diagnosis and treatment in these countries to minimise the risk of negative outcomes from undiagnosed and untreated ADHD.

Funding

This project was funded by a grant from the Hong Kong Research Grants Council Collaborative Research Fund (project number C7009-19G).

How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review

Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.

Meet the Medicines-A Crowdsourced Approach to Collecting and Communicating Information about Essential Medicines Online

The World Health Organization (WHO) maintains a list of medicines and medical devices, essential medicines, that should be available to everyone, to form a functioning healthcare system. Yet, many of these medicines remain out of reach for people around the world. One significant barrier to improving the accessibility of essential medicines is a paucity of information about both the extent and causes of this problem. E$$ENTIAL MEDICINE$ (E$$) is a citizen science project designed to investigate this deficit of information by recruiting members of the public to find, validate, compile and share information on essential medicines through an open, online database. Herein, we report an approach to crowdsourcing both the collection of information on the accessibility of essential medicines and the subsequent communication of these findings to diverse audiences. The Meet the Medicines initiative encourages members of the public to share information from the E$$ database, in a short video format appropriate for social media. This communication details the design and implementation of our crowdsourced approach and strategies for recruiting and supporting participants. We discuss data on participant engagement, consider the benefits and challenges of this approach and suggest ways to promote crowdsourcing practices for social and scientific good.

Impact of Coronavirus Disease COVID-19 on the Relationship between Healthcare Expenditures and Sustainable Economic Growth

The coronavirus disease (COVID-19) pandemic led to a catastrophic burden on the healthcare system and increased expenditures for the supporting medical infrastructure. It also had dramatic socioeconomic consequences. The purpose of this study is to identify the empirical patterns of healthcare expenditures' influence on sustainable economic growth in the pandemic and pre-pandemic periods. Fulfilment of the research task involves the implementation of two empirical blocks: (1) development of a Sustainable Economic Growth Index based on public health, environmental, social, and economic indicators using principal component analysis, ranking, Fishburne approach, and additive convolution; (2) modelling the impact of different kinds of healthcare expenditures (current, capital, general government, private, out-of-pocket) on the index using panel data regression modelling (random-effects GLS regression). Regression results in the pre-pandemic period show that the growth of capital, government, and private healthcare expenditures positively influence sustainable economic growth. In 2020-2021, healthcare expenditures did not statistically significantly influence sustainable economic growth. Consequently, more stable conditions allowed capital healthcare expenditures to boost economic growth, while an excessive healthcare expenditure burden damaged economic stability during the COVID-19 pandemic. In the pre-pandemic period, public and private healthcare expenditures ensured sustainable economic growth; out-of-pocket healthcare expenditures dominantly contributed to the pandemic period.

Decision criteria for selecting essential medicines and their connection to guidelines: an interpretive descriptive qualitative interview study

BACKGROUND AND OBJECTIVES

The World Health Organization Model List of Essential Medicines has led to at least 137 national lists. Essential medicines should be grounded in evidence-based guideline recommendations and explicit decision criteria. Essential medicines should be available, accessible, affordable, and the supporting evidence should be accompanied by a rating of the certainty one can place in it. Our objectives were to identify criteria and considerations that should be addressed in moving from a guideline recommendation regarding a medicine to the decision of whether to add, maintain, or remove a medicine from an essential medicines list. We also seek to explore opportunities to improve organizational processes to support evidence-based health decision-making more broadly.

METHODS

We conducted a qualitative study with semistructured interviews of key informant stakeholders in the development and use of guidelines and essential medicine lists (EMLs). We used an interpretive descriptive analysis approach and thematic analysis of interview transcripts in NVIVO v12.

RESULTS

We interviewed 16 key informants working at national and global levels across all WHO regions. We identified five themes: three descriptive/explanatory themes 1) EMLs and guidelines, the same, but different; 2) EMLs can drive price reductions and improve affordability and access; 3) Time lag and disconnect between guidelines and EMLs; and two prescriptive themes 4) An "evidence pipeline" could improve coordination between guidelines and EMLs; 5) Facilitating the link between the WHO Model List of Essential Medicines (WHO EML) and national EMLs could increase alignment.

CONCLUSION

We found significant overlap and opportunities for alignment between guideline and essential medicine decision processes. This finding presents opportunities for guideline and EML developers to enhance strategies for collaboration. Future research should assess and evaluate these strategies in practice to support the shared goal of guidelines and EMLs: improvements in health.

Access to medicines among the Brazilian population based on the 2019 National Health Survey

INTRODUCTION

Access to medicines is a challenge, especially in developing countries, highlighting the need of population-based research to evaluate access and related factors.

OBJECTIVE

This study aimed to assess access to medicines and identify associated factors using data from the 2019 Brazilian National Health Survey (PNS).

METHODS

This population-based cross-sectional study used data from the 2019 PNS and considered access to prescription medicines as the primary outcome. The sample included 24,753 individuals aged 15 years or older who looked for medical care in the last 15 days and received a medicine prescription. Andersen's behavioral model was used to select independent variables. After descriptive analysis, a multinomial logistic regression multilevel analysis was performed using the independent variables with a significance level lower than 0.20 in the bivariate analysis.

RESULTS

The lowest chances of getting access to medicines were observed in individuals aged between 40 and 59 years, women, with complete middle and high school, with lower-income families, who attended public services, with worse self-assessed health, and those who looked for health care for disease prevention and health promotion.

CONCLUSIONS

Access to medicines among the Brazilian population is associated with social, economic, and health perception factors. Our findings may update and guide the development of public policies on medication and pharmaceutical care, facilitating medication purchases by the care user and promoting health equity.

Essential medicines for mental disorders: comparison of 121 national lists with WHO recommendations

BACKGROUND

To compare the medicines for mental disorders included in national essential medicines lists with the World Health Organization (WHO) essential medicines list and assess the extent to which economic status and WHO Region account for the differences.

METHODS

We searched WHO repository and government sites for national essential medicines lists and we abstracted medicines for mental disorders. We calculated the proportion of WHO essential medicines included, the total number of differences (counting both additions and deletions) between national and WHO model list and the proportion of lists including one second-generation oral antipsychotic plus one new-generation antidepressant. Non-parametric statistics was used to investigate whether these indicators were dependent on economic status and WHO Region.

RESULTS

Amongst the 121 identified national lists, the total number of medicines for mental disorders ranged from 2 to 63 (median: 18; IQR: 14 to 25). The median proportion of WHO essential medicines for mental disorders included was 86% (IQR: 71-93%), with 16 countries (13%, 95% CI 7.75-20.5%) including all WHO essential medicines, while the median number of differences with the WHO EML was 11 (IQR: 7 to 15). Country economic level was positively associated with both the proportion of WHO essential medicines included (Spearman's rho = 0.417, p < 0.001) and the number of differences (Spearman's rho = 0.345, p < 0.001), implying that countries with higher income level included more WHO essential medicines, but also more additional medicines. Significant differences were observed in relation to WHO Region, with the African and Western Pacific Region showing the lowest proportions of WHO essential medicines, and the European Region showing the highest median number of differences. Overall, 88 national lists (73%, 95% CI 63-80%) included at least one second-generation oral antipsychotic and new-generation antidepressant, with differences by income level and WHO Region.

CONCLUSIONS

The degree of alignment of national lists with the WHO model list is substantial, but there are considerable differences in relation to economic status and WHO Region. These findings may help decision-makers to identify opportunities to improve national lists, aiming to increase access to essential medicines for mental disorders.

Understanding the implication of direct health facility financing on health commodities availability in Tanzania

The Government of Tanzania (GoT) has in the last decade made progress in strengthening the health system financing with progress towards Universal Health Coverage (UHC). The major reforms includes development of the health financing strategy, reforming the Community Health Fund (CHF) and introduction of the Direct Health Facility Financing (DHFF). DHFF was introduced in all district councils in the 2017/18 financial year. One of the anticipated goals of DHFF is to improve availability of health commodities. The objective of this study is to assess the effect of DHFF in improving the availability of health commodities in primary health care facilities. This study employed cross sectional study design, using quantitative techniques to analyze data related to expenditures and availability of health commodities at the primary health care facilities in Tanzania mainland. Secondary data was extracted from Electronic Logistics Management Information System (eLMIS) and Facility Financial Accounting and Reporting System (FFARS). Descriptive analysis was used to summarize the data using Microsoft Excel (2021) and inferential analysis was done using Stata SE 16.1. There has been an increase in allocation of funds for health commodities over the past three years. The Health Basket Funds (HBFs) accounted for an average of 50% of all health commodities expenditures. The complimentary funds (user fees and insurance) contributed about 20%, which is less than the 50% required by the cost sharing guideline. There is potentiality in DHFF improving visibility and tracking of health commodities funding. Implementation of DHFF has increased the amount of funding for health commodities at health facilities. The visibility and tracking of health commodity funding has improved. There is a scope of increasing health commodity funds at health facilities since the expenditures on health commodities is lower than what is indicated in the cost sharing collection and use guideline.

Expanding access to biotherapeutics in low-income and middle-income countries through public health non-exclusive voluntary intellectual property licensing: considerations, requirements, and opportunities

Biotherapeutics, such as recombinant proteins and monoclonal antibodies, have become mainstays of modern medicine as shown by their increasing number in the WHO Model List of Essential Medicines. However, despite frequently offering clinical advantages over standards of care, they remain largely out of reach for populations in low-income and middle-income countries (LMICs), partly because of high costs. Accordingly, the WHO Model List of Essential Medicines Expert Committee has requested that the Medicines Patent Pool explore intellectual property licensing to address this challenge. We therefore investigated how licensing could successfully improve affordability of and timely access to biotherapeutics in LMICs, by leveraging expert consultations, literature analysis, and internal technical knowledge. The key elements identified as relevant to support access to affordable biosimilars in LMICs through licensing include: prioritising potential biotherapeutic targets according to their potential for public health impact; supporting biosimilar product and clinical development (including through technology transfer to expedite regulatory approval); and facilitating biosimilars' entry and use in LMICs (by meeting procurement, supply chain, and health system requirements).

Reimbursement and payment models in Central and Eastern European as well as Middle Eastern countries: A survey of their current use and future outlook

There is growing interest in innovative reimbursement and payment models in Central and Eastern European (CEE) and Middle Eastern (ME) countries. A questionnaire was sent to payers from CEE and ME countries regarding the current use of, future preferences for and perceived barriers with these models. Twenty-seven healthcare payers from 11 countries completed the survey. Results showed participants preferred using outcome-based reimbursement models and delayed payment models more often; however, currently they are rarely applied. Barriers hindering implementation were mostly related to IT and data infrastructure, measurement issues, transaction costs and the administrative burden. Given these barriers highlighted in our study, policymakers should focus on the development of an implementation framework with contract templates for the preferred reimbursement and payment schemes to aid the feasibility of a successful implementation.

Can we move beyond vaccine apartheid? Examining the determinants of the COVID-19 vaccine gap

While global health leaders call disparities in access to COVID-19 vaccines an 'apartheid,' this gap is not the first such disparity. The recurrence of these gaps in low and middle-income countries and especially in Africa, raises questions about their determinants and about the persistent failures of global health institutions to remediate them. We interrogate these determinants and questions by examining: (1) the distribution of COVID-19 vaccines; (2) primary determinants of vaccine access including availability and affordability; (3) factors affecting availability (hoarding, COVAX, and manufacturing capacity); and (4) factors affecting affordability (pricing, intellectual property rights (IPR), the TRIPS waiver and a potential pandemic treaty). We conclude that IPR constrained the affordability and availability of COVID-19 vaccines in ways inadequately addressed by COVAX and a waiver compromise thwarted by political, corporate, and philanthropic interests. While stronger limits to IPR in a pandemic treaty and a reformed International Health Regulations will not resolve structural inequities, they could meaningfully expand LMIC autonomy to protect public health. We urge equity-seeking Global South and North actors to fight for such IPR reforms as small and meaningful steps towards a more equitable global health order. Otherwise, criminally racist 'apartheids' will continue to be the norm when it comes to the distribution of essential health goods during global health emergencies.

When Reality Does Not Meet Expectations-Experiences and Perceived Attitudes of Dutch Stakeholders Regarding Payment and Reimbursement Models for High-Priced Hospital Drugs

This study aimed to identify the current experiences with and future preferences for payment and reimbursement models for high-priced hospital therapies in the Netherlands, where the main barriers lie and assess how policy structures facilitate these models. A questionnaire was sent out to Dutch stakeholders (in)directly involved in payment and reimbursement agreements. The survey contained statements assessed with Likert scales, rankings and open questions. The results were analyzed using descriptive statistics. Thirty-nine stakeholders (out of 100) (in)directly involved with reimbursement decision-making completed the survey. Our inquiry showed that currently financial-based reimbursement models are applied most, especially discounts were perceived best due to their simplicity. For the future, outcome-based reimbursement models were preferred, particularly pay-for-outcome models. The main stated challenge for implementation was generating evidence in practice. According to the respondents, upfront payments are currently implemented most often, whereas delayed payment models are preferred to be applied more frequently in the future. Particularly payment-at-outcome-achieved models are preferred; however, they were stated as administratively challenging to arrange. The respondents were moderately satisfied with the payment and reimbursement system in the Netherlands, arguing that the transparency of the final agreements and mutual trust could be improved. These insights can provide stakeholders with future direction when negotiating and implementing innovative reimbursement and payment models. Attention should be paid to the main barriers that are currently perceived as hindering a more frequent implementation of the preferred models and how national policy structures can facilitate a successful implementation.

Substandard and falsified medical product recalls in Zambia from 2018 to 2021 and implications on the quality surveillance systems

Background

Substandard and falsified (SF) medical products are removed from circulation through a process called 'product recall' by medicines regulatory agencies. In Zambia, the Zambia Medicines Regulatory Authority (ZAMRA) is responsible for recalling SF medical products from the Zambian market through passive and active surveillance methods. This study aimed to describe the prevalence of recalls of SF medical products and to analyse the frequently recalled therapeutic categories, dosage forms, categories of defects that led to the recalls and their sources with respect to the country of the marketing authorisation holder (MAH) or manufacturer.

Methods

We conducted a descriptive cross-sectional review of the product recalls issued by ZAMRA between January 2018 and December 2021. A search for all medical product alerts and recalls issued by ZAMRA was carried out by reviewing the internal post-marketing surveillance database kept at ZAMRA headquarters. Data were extracted using a structured Excel database and analysed using Microsoft Excel.

Results

A total of 119 alerts were received during the review period, of which 83 (69.7%) were product recalls. Oral solid dosage forms were the most recalled dosage form (53%). Furthermore, the number of recalls increased in 2020 (44.6%) and 2021 (22.9%), with the majority (20.5%) of the recalled products being substandard products classified as antiseptics and disinfectants and were attributed to the high demand during the COVID-19 pandemic. Manufacturing laboratory control issues were the reason for product recall in almost half (47.4%) of the cases. Most of the products recalled originated from India (38.6%), followed by Zambia (25.3%). Only one suspected falsified product was recalled between 2018 and 2021. A total of 66 recalls of the 83 products were initiated by ZAMRA, with only 17 voluntarily by foreign MAHs. No product recall was initiated by the local representatives of foreign manufacturers or MAH.

Conclusion

The majority of the pharmaceutical product recalls in Zambia were substandard products. Manufacturing laboratory control issues lead to most recalls and require investigation of the root causes, preventive action, and strict compliance with the good manufacturing practices guidelines by manufacturers.

Implementing essential diagnostics-learning from essential medicines: A scoping review

The World Health Organization (WHO) model list of Essential In vitro Diagnostic (EDL) introduced in 2018 complements the established Essential Medicines List (EML) and improves its impact on advancing universal health coverage and better health outcomes. We conducted a scoping review of the literature on implementing the WHO essential lists in Africa to inform the implementation of the recently introduced EDL. We searched eight electronic databases for studies reporting on implementing the WHO EDL and EML in Africa. Two authors independently conducted study selection and data extraction, with disagreements resolved through discussion. We used the Supporting the Use of Research Evidence (SURE) framework to extract themes and synthesised findings using thematic content analysis. We used the Mixed Method Appraisal Tool (MMAT) version 2018 to assess the quality of included studies. We included 172 studies reporting on EDL and EML after screening 3,813 articles titles and abstracts and 1,545 full-text papers. Most (75%, n = 129) studies were purely quantitative in design, comprising descriptive cross-sectional designs (60%, n = 104), 15% (n = 26) were purely qualitative, and 10% (n = 17) had mixed-methods approaches. There were no qualitative or randomised experimental studies about EDL. The main barrier facing the EML and EDL was poorly equipped health facilities-including unavailability or stock-outs of essential in vitro diagnostics and medicines. Financial and non-financial incentives to health facilities and workers were key enablers in implementing the EML; however, their impact differed from one context to another. Only fifty-six (33%) of the included studies were of high quality. Poorly equipped and stocked health facilities remain an implementation barrier to essential diagnostics and medicines. Health system interventions such as financial and non-financial incentives to improve their availability can be applied in different contexts. More implementation study designs, such as experimental and qualitative studies, are required to evaluate the effectiveness of essential lists.

Regulatory policy and pharmaceutical innovation in the United Kingdom after Brexit: Initial insights

Brexit was presented as an opportunity to promote innovation by breaking free from the European Union regulatory framework. Since the beginning of 2021 the Medicines and Healthcare products Regulatory Agency (MHRA) has operated as the independent regulatory agency for the United Kingdom. The MHRA's regulatory activity in 2021 was analyzed and compared to that of other international regulatory bodies. The MHRA remained reliant on EU regulatory decision-making for novel medicines and there were significant regulatory delays for a small number of novel medicines in the UK, the reasons being so far unclear. In addition, the MHRA introduced innovation initiatives, which show early promise for quicker authorization of innovative medicines for cancer and other areas of unmet need. Longer-term observation and analysis is needed to show the full impact of post-Brexit pharmaceutical regulatory policy.

Implementation of medicines pricing policies in sub-Saharan Africa: systematic review

BACKGROUND

High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries?

METHODS

We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines.

RESULTS

Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines.

CONCLUSIONS

Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a 'one-size-fits-all' approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178166.

The challenge of institutionalised complicity: Researching the pharmaceutical industry in the era of impact and engagement

The pharmaceutical industry plays a central role in the production of the drugs we use to treat most illnesses. It is immensely powerful and has received sustained attention from sociologists of health and illness, who have provided a critique of its influence and sometimes unethical behaviour. However, in recent years, funders are increasingly expecting researchers to engage and collaborate with stakeholders, including industry. This raises important questions about the institutionalisation of complicity and the different forms this might take. This article asks: How can sociologists engage with the pharmaceutical industry in a positive and constructive manner, whilst remaining independent, principled and critical? It will draw on my experience of establishing a major project on high-priced drugs for rare diseases and the literature on collaboration, stakeholder engagement and responsible research to propose a methodological framework to address this challenge. This is based on six PRIMES: (normative) Principles, Reflection and Independence, (field) Mapping, (careful) Engagement and Strategic intervention that have broad applications to many other areas of contemporary social science research.

Essential substance use disorder medications in Asia Pacific countries: An observational study

AIM

To analyze national lists of essential medicines (NLEM) of Asia Pacific countries for inclusion of substance use disorder (SUD) medications.

METHODS

An observational study was conducted using the most recent versions of NLEM of all 55 Asia Pacific countries till April, 2022. SUD medication details were extracted and analyzed.

RESULTS

NLEM of included nations contained a median 2 medications for long term SUD management. Sixteen countries had atleast one medication for opioid use disorder and 13 for alcohol use disorder. Four countries had atleast one medication for opioid, alcohol, and tobacco use disorders.

CONCLUSION

NLEM expansion is needed considering public health burden of SUDs.

Explanation of Socio-economic Inequality in Medicine Use: A Cross-sectional Analysis from Iran

Background

Despite the favorable progress in the production of medicines, there is no significant access to these important health inputs among different socio-economic groups.

Objectives

This study aimed to measure and explain socio-economic inequality in prescribed and non-prescribed medicine use in Iran.

Methods

Data were obtained from a recent household survey on health services in Iran conducted in 2016. The Erreygers concentration index (ECI) was used to measure socio-economic inequality in the use of prescribed and non-prescribed medicines. In addition, Decomposition analysis was conducted to explain socio-economic inequality.

Results

The ECI revealed pro-rich socio-economic inequality in prescribed medicine use (ECI = 0.067, SE = 0.010), indicating that prescribed medicine use was concentrated on the better-offs. On the other hand, this index showed pro-poor inequality in non-prescribed medicine use (ECI = -0.064, SE = 0.009). Decomposition analysis showed that economic status and place of residence were the main determinants of socio-economic inequality in prescribing medicines. These factors and the number of health care needs explained the majority of socio-economic inequality in non-prescribed medicine use.

Conclusions

Despite previous positive beliefs, we found remarkable socio-economic inequality in the use of medicines in Iran. Facilitating access to pharmaceutical services for disadvantaged households and rural residents and promoting of national essential medicines list could be recommended against socio-economic inequality in the pharmaceutical market of Iran.

Framing access to essential medicines in the context of Universal Health Coverage: a critical analysis of health sector strategic plans from eight countries in the WHO African region

BACKGROUND

Framing affects how issues are understood and portrayed. This profoundly shapes the construction of social problems and how policy options are considered. While access to essential medicines (ATM) in the World Health Organization (WHO) African Region is often framed as a societal problem, there is dominance of medical and technically oriented approaches to analyze and remedy the situation. Hence, the systematic application of social science approaches, such as framing theory, remains under-explored. Through a framing analysis of National Strategic Plans (NSPs) from eight countries, this study explores the applicability and potential usefulness of framing theory to analyze essential medicines policies.

METHODS

We inductively coded the relevant NSP textual fragments using the qualitative content analysis software ATLAS.ti.22. Benford and Snow's conceptualization of framing was used to organize the coded data into three frames: diagnostic (problems), prognostic (solutions) and motivational (values and ideological).

RESULTS

The following five diagnostic frames were dominant or in-frame: medicine unavailability, ineffective regulation, weak supply chain management, proliferation of counterfeit (substandard or falsified) medicines and use of poor quality medicines. Diagnostic frames related to financing, affordability, efficiency and corruption were given limited coverage or out of frame. Prognostic frames corresponded with how these problems were framed. Whilst Universal Health Coverage (UHC) and its guiding principles was the dominant motivational frame, we identified some frame discordance between the global discourse and national level policies.

CONCLUSIONS

Social science approaches such as framing analysis are applicable and useful to systematically analyze essential medicine aspects. By applying framing theory, we revealed that ATM aspects in the eight countries we analyzed are more often characterized in relation to availability at the expense of affordability which undermines UHC. We conclude that whilst UHC is a strong motivational frame to guide ATM aspects, it is insufficient to inform a comprehensive approach to address the problems related to ATM at country level. To effectively advance ATM, concerned actors need to realize such limitation and endeavor to gain a deeper understanding of how problems are framed and agendas are set at country level, the processes through which ideas and knowledge become policies, including the political demands, incentives and trade-offs facing decision-makers in selecting policy priorities.