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.

Childhood blood lead levels and environmental risk factors in Madagascar

One-third of children globally have blood lead levels (BLLs) exceeding the (former) US CDC reference value of 5 µg/dL; this value may be as high as one-half for children in low- and middle-income countries (LMICs). Lead exposure occurs through a variety of routes (e.g., water, dust, air), and in LMICs specifically, informal economies (e.g., battery recycling) can drive lead exposures due, in part, to absent regulation. Previous work by our team identified a ubiquitous source of lead (Pb), in the form of Pb-containing components used in manually operated pumps, in Toamasina, Madagascar. Characterization of BLLs of children exposed to this drinking water, and identification of additional exposure routes were needed. BLLs were measured for 362 children (aged 6 months to 6 years) in parallel with surveying to assess 14 risk factors related to demographics/socioeconomics, diet, use of pitcher pumps, and parental occupations. BLL data were also compared against a recent meta-review of BLLs for LMICs. Median childhood BLL (7.1 µg/dL) was consistent with those of other Sub-Saharan African LMICs (6.8 µg/dL) and generally higher than LMICs in other continents. Risk factors significantly associated (p < 0.05, univariate logistic regression) with elevated BLL (at ≥ 5 µg/dL) included male gender, living near a railway or major roadway (owing potentially to legacy lead pollution), having lower-cost flooring, daily consumption of foods (beans, vegetables, rice) commonly cooked in recycled aluminum pots (a previously identified lead source for this community), and a maternal occupation (laundry-person) associated with lower socioeconomic status (SES). Findings were similar at the ≥ 10 µg/dL BLL status. Our methods and findings may be appropriate in identifying and reducing lead exposures for children in other urbanizing cities, particularly in Sub-Saharan Africa, where lead exposure routes are complex and varied owing to informal economics and substantial legacy pollution.

Availability, cost and affordability of selected antibiotics and antiviral medicines against infectious diseases from 2013 to 2019 in Nanjing, China

OBJECTIVES

As economic globalisation develops in-depth, infectious diseases that occur in a country or region no longer remains a regional issue. Antibiotics and antiviral medicines are essential medicines for the therapy of infectious diseases. This study aims to evaluate their availability, cost and affordability of AaAMs against infectious diseases in 41 public hospitals from 2013 to 2019 in Nanjing, China.

METHODS

Data on the availability and price of 17 antibiotics and 6 antiviral medicines in 41 public hospitals were obtained from the Jiangsu Institute of Medicine Information. We adopted the WHO/Health Action International method to measure the availability, cost and affordability of these medicines.

RESULTS

The availability of selected medicines against infectious diseases was relatively low; the median availability of originator brands was near-zero and that of lowest-priced generics during the survey period less than 50%. The total availability of medicines was poor in primary hospitals as compared to secondary and tertiary hospitals. The median daily-defined dose cost of originator brands was expensive (range from 66.11 RMB to 107.83 RMB), whereas that of lowest price generics was fairly acceptable at < 8 RMB. The affordability of most surveyed medicines was reasonable, which showed significant improvement over time, but the daily cost of a few medicines for originator brands exceeded the average daily wage.

CONCLUSIONS

In general, the affordability of medicines surveyed was acceptable, while the availability was too low. There should be a great concern for improving the reserve system of anti-infective medicines in healthcare institutions. Policy should focus on improving the availability of generic drugs in hospitals and encouraging preferentially prescribed.

The Effect of the Full Coverage of Essential Medicines Policy on Utilization and Accessibility of Primary Healthcare Service for Rural Seniors: A Time Series Study in Qidong, China

Background: Since 2015, in order to handle the increasing prevalence of age-related diseases and escalating health expenditures arising from the aging population, the full coverage of essential medicines (FCEMs) policy for rural seniors has been implemented in primary healthcare institutions of Qidong County of Jiangsu, China. The purpose of this study is to examine the long-term effects of the introduction of FCEMs' policy on the utilization and accessibility of primary healthcare service for elderly beneficiaries. Methods: The retrospective study was conducted in Qidong County in the Jiangsu province, China. A 47-month longitudinal dataset involving 91,444 health insurance claims records of inpatients aged 70 and older in primary healthcare institutions was analyzed. Changes in health service utilization (average length of stay), patient copayments (out-of-pocket expenses), New Rural Cooperative Medical System (NRCMS) reimbursement rate and daily hospitalization costs per patient were analyzed using interrupted time series analysis. Augment Dicky-Fuller unit root method was used to test the stationarity of the series alongside the Durbin Watson method to test autocorrelation. Results: Average length of stay increased at 0.372 bed-days per month before the implementation of FCEMs policy, whereas the increasing trend was slowed down at 0.003 bed-days per month after the implementation of FCEMs policy (p < 0.001). The average out-of-pocket expenses increased by 38.035 RMB monthly in pre-implementation of the policy period, but it decreased at the rate of 5.180 RMB per month after the implementation of the FCEMs policy (p = 0.006). The NRCMS reimbursement rate increased at 0.066% per month in pre-implementation of policy and the increasing trend was sharper at 0.349% in post-implementation of policy (p = 0.135). The daily hospitalization costs per patient decreased by 6.263 RMB (p = 0.030) per month, whereas it increased at the rate of 3.119 RMB (p = 0.002) per month afterwards. Conclusions: Based on interrupted time series analyses, we concluded that FCEMs policy was associated with positive changes of average LOS and average OOP expenses. The FCEMs policy has alleviated the financial burden of the rural seniors and slightly improved the efficiency of primary health service utilization. However, it had no positive effect on daily hospitalization costs. Therefore, in the general framework of FCEMs policy, the Chinese health policy-maker should take necessary supporting measures to curb climbing hospitalization expenditures and promote the rational drug use in primary healthcare institutions.

How much does community-based targeting of the ultra-poor in the health sector cost? Novel evidence from Burkina Faso

BACKGROUND

Targeting efforts aimed at increasing access to care for the poorest by reducing to a minimum or completely eliminating payments at point of use are increasingly being adopted across low and middle income countries, within the framework of Universal Health Coverage policies. No evidence, however, is available on the real cost of designing and implementing these efforts. Our study aimed to fill this gap in knowledge through the systematic assessment of both the financial and economic costs associated with designing and implementing a pro-poor community-based targeting intervention across eight districts in rural Burkina Faso.

METHODS

We conducted a partial retrospective economic evaluation (i.e. estimating costs, but not benefits) associated with the abovementioned targeting intervention. We adopted a health system perspective, including all costs incurred by the government and its development partners as well as costs incurred by the community when working as volunteers on behalf of government structures. To trace both financial and economic costs, we combined Activity-Based Costing with Resource Consumption Accounting. To this purpose, we consulted and extracted information from all relevant design/implementation documents and conducted additional key informant structured interviews to assess the resource consumption that was not valued in the documents.

RESULTS

For the entire community-based targeting intervention, we estimated a financial cost of USD 587,510 and an economic cost of USD 1,213,447. The difference was driven primarily by the value of the time contributed by the community. Communities carried the main economic burden. With a total of 102,609 ultra-poor identified, the financial cost and the economic cost per ultra-poor person were respectively USD 5,73 and USD 11,83.

CONCLUSION

The study is first of its kind to accurately trace the financial and economic costs of a community-based targeting intervention aiming to identify the ultra-poor. The financial costs amounted to USD 5,73 and the economic costs to USD 11,83 per ultra-poor person identified. The financial costs of almost USD 6 represents 21% of the per capita government expenditure on health.

In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage

Despite overwhelming burdens of disease, health care access in most developing countries is extremely low. As governments work toward achieving universal health coverage, evidence on appropriate interventions to expand access in rural populations is critical for informing policies. Using a combination of population and health system data, we evaluated the impact of two pilot fee exemption interventions in a rural area of Madagascar. We found that fewer than one-third of people in need of health care accessed treatment when point-of-service fees were in place. However, when fee exemptions were introduced for targeted medicines and services, the use of health care increased by 65 percent for all patients, 52 percent for children under age five, and over 25 percent for maternity consultations. These effects were sustained at an average direct cost of US$0.60 per patient. The pilot interventions can become a key element of universal health care in Madagascar with the support of external donors.

Analysis of agency relationships in the design and implementation process of the equity fund in Madagascar

Background

There are large gaps in the literature relating to the implementation of user fee policy and fee exemption measures for the poor, particularly on how such schemes are implemented and why many have not produced expected outcomes. In October 2003, Madagascar instituted a user fee exemption policy which established “equity funds” at public health centres, and used medicine sales revenue to subsidise the cost of medicine for the poor. This study examines the policy design and implementation process of the equity fund in Madagascar in an attempt to explore factors influencing the poor equity outcomes of the scheme.

Methods

This study applied an agency-incentive framework to investigate the equity fund policy design and implementation practices. It analysed agency relationships established during implementation; examined incentive structures given to the agency relationships in the policy design; and considered how incentive structures were shaped and how agents responded in practice. The study employed a case-study approach with in-depth analysis of three equity fund cases in Madagascar’s Boeny region.

Results

Policy design problems, triggering implementation problems, caused poor equity performance. These problems were compounded by the re-direction of policy objectives by health administrators and strong involvement of the administrators in the implementation of policy. The source of the policy design and implementation failure was identified as a set of principal-agent problems concerning: monitoring mechanisms; facility-based fund management; and the nature and level of community participation. These factors all contributed to the financial performance of the fund receiving greater attention than its ability to financially protect the poor.

Conclusion

The ability of exemption policies to protect the poor from user fees can be found in the details of the policy design and implementation; and implications of the policy design and implementation in a specific context determine whether a policy can realise its objectives. The equity fund experience in Madagascar, which illustrates the challenges of beneficiary identification, casts doubts on the application of the ‘targeting’ approach in health financing and raises issues to be considered in universal health policy formulation. The agency framework provides a useful lens through which to examine policy process issues.

A community-based approach to indigent selection is difficult to organize in a formal neighbourhood in Ouagadougou, Burkina Faso: a mixed methods exploratory study

Background

In most African countries, indigents treated at public health centres are supposed to be exempted from user fees. In Africa, most of the available knowledge has to do with targeting processes in rural areas, and little is known about how to select the worst-off in an urban area. In rural communities of Burkina Faso, trials of participatory community-based selection of indigents have been effective. However, the process for selecting indigents in urban areas is not yet clear.

Methods

This study evaluates a community-funded participatory indigent selection process in both a formal (loti) and an informal (non-loti) neighbourhood in the urban setting of Burkina Faso’s capital. This was an exploratory study to evaluate the processes and effectiveness of participatory targeting. We conducted individual interviews (n = 26) and analyzed secondary qualitative data (eight focus groups, 16 individual interviews). We also used the results of a socioeconomic survey (carried out by the Ouaga HDSS in 2011) of all the households established in the areas, including those of selected indigents.

Results

The coverage of indigent targeting was very low: 0.33% (loti) and 0.22% (non loti). In the non loti neighbourhood, the level of poverty among people selected was higher than the mean level of the poor who were not selected. Some indigents selected in the loti neighbourhood were not among the worst-off. The process was difficult to organize in the loti neighbourhood; people knew each other less well and were not very available, and there were cases of collusion. The process worked well in the non loti neighbourhood.

Conclusions

This intervention research provides new evidence about the feasibility of a community-based selection process in an urban setting in Africa by comparing two different urban settings. The participatory community-based selection process appeared to be suitable for the non loti neighbourhood, but other targeting strategies need to be found for loti areas. Specific budgets need to be allocated to increase the coverage of indigent targeting.