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

The antibiotic procurement saga: a long-neglected stewardship target to combat antimicrobial resistance in Pakistan

BACKGROUND

Consistent and timely access to antibiotics is a hallmark of an antimicrobial stewardship program (ASP) and can be achieved through good procurement practices. However, flawed procurement modules result in poor antibiotic supply management within health facilities of low- and middle-income countries (LMICs), including Pakistan, exacerbating antimicrobial resistance (AMR). This study seeks to understand hospital pharmacists' perspectives on the antibiotic procurement process, its efficiency in ensuring consistent access to antibiotics, and the role of clinical pharmacists in rational procurement.

METHODS

Semi-structured interviews with 24 purposively selected hospital pharmacists from secondary healthcare facilities in Punjab, Pakistan, were conducted utilizing a qualitative case study methodology. Data analysis was conducted using MAXQDA 2024 software, following a thematic analysis technique using a codebook approach to thematic analysis.

RESULTS

The study identified five central themes: (1) The state of antibiotic use in hospitals is characterized by a lack of antibiotic use policy, resulting in mostly empirical and irrational prescribing practices. (2) Medicine availability significantly influences prescribing decisions, often taking precedence over clinical needs. (3) The procurement process, although structured, is flawed owing to rigid adherence to the Standard Medicine List (SML). (4) Rationality in procurement is compromised by disregard for AMR, with decisions driven more by cost and demand than clinical evidence. (5) The clinical acumen of pharmacists is underutilized in procurement due to multifarious barriers.

CONCLUSION

Antibiotic procurement is the mainstay of implementing an ASP in hospitals. This study elucidates significant policy, practice, and education gaps regarding antibiotic use and procurement in Pakistan. There is a critical need for comprehensive antibiotic policies, including a revision in SML, enhancing pharmacist authority in procurement decisions, more rational prescribing, and ensuring access to antibiotics through more informed and data-driven processes to combat AMR effectively.

The process of ratifying the treaty to establish the African Medicines Agency: perspectives of national regulatory agencies

The vision of the African Medicines Agency (AMA) is to ensure that all Africans have access to affordable medical products that meet internationally recognized standards of quality, safety and efficacy for priority diseases/conditions. The AMA is being established by a treaty which had to be ratified by a minimum of 15 African countries. Although there was no deadline, the ratification process has been slower than expected. This study therefore analysed the rationale, perceived benefits, enabling factors and challenges of the AMA's establishment. This study was a qualitative, cross-sectional, census survey of the national medicines regulatory authorities (NRAs) of 45 African countries. The Heads of NRAs and a senior NRA staff member were contacted to complete self-administered questionnaires. The existence of mature NRAs, the desire to have harmonized regulatory systems, the presence of strong political will and appropriate advocacy to expedite treaty signing are all enabling factors for AMA treaty signing. The challenges reported include the fact that the process is slow and there is limited understanding of the process. Competing national priorities, changes in office bearers in the public system and stagnation of the process at the ministerial level were also challenges reported. This study has improved the understanding of the treaty signing and ratification process and the perceived benefits and enabling factors of signing and ratification from African NRAs' perspective. NRAs also highlighted challenges encountered in the process. Addressing these challenges will result in effective medicines regulation by galvanizing technical support, regulatory expertise and resources at a continental level.

Developing Nepal's medicines pricing policy: evidence synthesis and stakeholders' consultation

Objectives

The objectives of this paper are to (a) explore stakeholders' opinions regarding Nepal's existing medicines pricing practices/situation and (b) build and present a set of medicines pricing policies for Nepal.

Methods

A review of the literature and field visits to community retail pharmacies, hospital pharmacies, wholesalers, and distributor outlets in Kathmandu were conducted to assess the medicines pricing situation. Following the literature review, preliminary meetings with stakeholders and field visits were held and a draft interview guide was prepared. Consultative sessions subsequently were undertaken in Kathmandu, Nepal, in January 2023 with representatives from the Department of Drug Administration, Ministry of Health and Population, Association of Pharmaceutical Producers of Nepal, consumer groups, Transparency International, Medicines Importers Association of Nepal/ Pharmaceutical Distributors Association of Nepal, Nepal Chemist and Druggist Association, and Nepal Pharmaceutical Association. Notes were taken during these meetings regarding issues and concerns raised as well as experiences and recommendations for the future, as outlined in the interview guide.

Results

The stakeholders in general stated that they do not have any objection to price regulation; however, they believe such regulation should be subject to periodic review. Both the importers and the Ministry of Health and Population have the view that an independent body/authority should be charged with regulating the prices of medicines. A set of policy options to be considered for use in Nepal include cost-plus pricing, external price referencing, internal reference pricing, and mark-up regulations.

Conclusion

Key issues related to pricing were identified and suggest that a set of pricing policies and updated regulations need to be considered to establish changes that are transparent, rational, and acceptable to the related stakeholders. Hence, suggestions made in this paper could be useful to inform a rational and fair pricing structure and to improve access to medicines.

Implementation of Medicines Pricing Policies in Ghana: The Interplay of Policy Content, Actors' Participation, and Context

BACKGROUND

Implementing medicines pricing policy effectively is important for ensuring equitable access to essential medicines and ultimately achieving universal health coverage. However, published analyses of policy implementations are scarce from low- and middleincome countries. This paper contributes to bridging this knowledge gap by reporting analysis of implementation of two medicines pricing policies in Ghana: value-added tax (VAT) exemptions and framework contracting (FC) for selected medicines. We analysed implications of actor involvements, contexts, and contents on the implementation of these policies, and the interplay between these. This paper should be of interest, and relevance, to policy designers, implementers, the private sector and policy analysts.

METHODS

Data were collected through document reviews (n=18), in-depth interviews (n=30), focus groups (n=2) and consultative meetings (n=6) with purposefully identified policy actors. Data were analysed thematically, guided by the four components of the health policy triangle framework.

RESULTS

The nature and complexity of policy contents determined duration and degree of formality of implementation processes. For instance, in the FC policy, negotiating medicines prices and standardizing the tendering processes lengthened implementation. Highly varied stakeholder participation created avenues for decision-making and promoted inclusiveness, but also raised the need to manage different agendas and interests. Key contextual enablers and constraints to implementation included high political support and currency depreciation, respectively. The interrelatedness of policy content, actors, and context influenced the timeliness of policy implementations and achievement of intended outcomes, and suggest five attributes of effective policy implementation: (1) policy nature and complexity, (2) inclusiveness, (3) organizational feasibility, (4) economic feasibility, and (5) political will and leadership.

CONCLUSION

Varied contextual factors, active participation of stakeholders, nature, and complexity of policy content, and structures have all influenced the implementation of medicines pricing policies in Ghana.