The right to health as the basis for universal health coverage: A cross-national analysis of national medicines policies of 71 countries

Unpacking the process of developing South Africa's national drug policy - lessons for universal health coverage

Background

South Africa's National Drug Policy (NDP) was first issued in 1996, at a time of considerable political change.

Objectives

To revisit the lessons learned from the process of development and initial implementation of the NDP.

Methods

Six in-depth face-to-face interviews were held with purposively-selected key actors. Interviews, which followed pre-determined semi-structured questions, but were allowed to explore additional areas, were recorded and transcribed, and then subjected to abductive thematic analysis, informed by the Walt and Gilson model.

Results

Three key themes emerged, described as 'evidence', 'trust' and 'looking forward'. A paucity of evidence backed some of the key concepts in the NDP, and these have not been addressed as evidence has matured. The lack of trust which characterised the policy process impacted on the ways in which actors were able to or not able to engage, and therefore on the resultant content and the choices exercised. The coherence of the policy, its articulation with other health reforms, and its contribution to subsequent efforts to ensure universal health coverage in South Africa have all been weakened by the failure to revise the document over time.

Conclusion

As South Africa advances its plans for universal health coverage, there is an urgent need to revisit key components of the NDP which are no longer fit for purpose.

Litigation in access to universal health coverage for children and adolescents in Brazil

Background

Brazil's Unified Health System (SUS) ensures universal, equitable, and excellent quality health coverage for all. The broad right to health, supported by the Constitution, has led to excessive litigation in the public sector. This has negatively impacted the financial stability of SUS, created inequality in children and adolescents' access to healthcare, and affected communication between the healthcare system and the judiciary. The enactment of Law Number 13.655 on 25 April 2018, proposed significant changes in judicial decisions. This study aimed to investigate decision-making changes in health litigation involving children and adolescents following the implementation of the new normative model.

Methods

The study is cross-sectional, analyzing 3753 national judgment documents from all State Courts of Brazil, available on their respective websites from 2014 to 2020. It compares regional legal decisions before and after the promulgation of Law Number 13.655/2018. Data tabulation, statistical analysis, textual analysis, coding, and counting of significant units in the collected documents were performed. The results of data cross-referencing are presented in tables and diagrams.

Results

The majority (96.86%) of legal claims (3635 cases) received partial or total provision of what was prescribed by the physician. The Judiciary predominantly handled these cases individually. The analysis indicates that the decisions made did not adhere to the norms established in 2018.

Conclusion

Regional heterogeneity in health litigation was observed, and there was no significant variability in decisions during the studied period, even after the implementation of the new normative paradigm in 2018. Technical-scientific support was undervalued by the magistrates. Prioritizing litigants undermines equity in access to Universal Health Coverage for children and adolescents.

A proposed analytical framework for qualitative evaluation of access to medicines from a health systems perspective

OBJECTIVE

Despite global recognition that access to medicines is shaped by various interacting processes within a health system, a suitable analytical framework for identifying barriers and facilitators from a system's perspective was needed. We propose a framework specifically designed to find drivers to access to medicines from a country's health system perspective. This framework could enable the systematic evaluation of access across countries, disease areas and populations and facilitate targeted policy development. This framework is the byproduct of a larger study on the barriers and facilitators to childhood oncology medicines in South Africa.

RESULTS

Eight core (pharmaceutical) functional processes were identified from existing frameworks: (I) medicine regulation, (II) public financing and pricing, (III) selection, (IV) reimbursement, (V) procurement and supply, (VI) healthcare delivery, (VII) dispensing and (VIII) use. National contextual components included policy and legislation and health information systems. To emphasize the interlinkage of processes, the proposed framework was structured as a pharmaceutical value chain. This framework focusses on national processes that are within a country's control as opposed to global factors, and functional mechanisms versus a country's performance or policy objectives. Further refinement and validation of the framework following application in other contexts is encouraged.

Relationship between health insurance enrolment and unintended pregnancy in Ghana

CONTEXT

The effect of health insurance coverage on sexual and reproductive health, especially unintended pregnancy, has scantly been researched. Using the 2014 Ghana Demographic and Health Survey, the study examined the links between women's health insurance enrolment on unintended pregnancy in Ghana.

METHOD

The sample consisted of 9,396 women aged 15-49 years, but the analysis was limited to the 4,544 women who were pregnant in the two years preceding the survey. The effects of health insurance enrolment on unintended pregnancy was examined with the propensity score matching. The health insurance enrolment was the treatment variable and unintended pregnancy as the outcome variable.

RESULTS

This study showed that 66.0% of all women surveyed had health insurance coverage and 31.8% of all women of childbearing age who were currently or had previously been pregnant reported having at least one unintended pregnancy. Thirty percent of insured women had an unintended pregnancy, compared to 37% of uninsured women. The results showed that education, household wealth index, religion, and type of marital union were significant predictor of health insurance coverage among Ghanaian women. The PSM split the women based on their health insurance status. After matching, the difference between the insured and uninsured women reduces significantly. Results demonstrated that, the probability of unintended pregnancy was 0.312 among insured women and 0.351 among those not insured in Ghana. This implies that having health insurance coverage will help in reducing the likelihood of women experiencing unintended pregnancy.

CONCLUSIONS

Results highlight the importance of the target of universal health coverage under the sustainable development goal 3 and demonstrate that expanding existing health insurance schemes within Ghana could contribute to reducing the number unintended pregnancies experienced each year.

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.

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.

[Prevalence rates and inequalities in access to medicines by users of the Brazilian Unified National Health System in 2013 and 2019]

The study aimed to analyze and compare the prevalence of access to medicines and associated factors among users of the Brazilian Unified National Health System (SUS). The authors analyzed data from the 2013 and 2019 editions of the Brazilian National Health Survey, a nationwide health study, representative of the Brazilian population. The outcomes were: (1) obtaining from the SUS all the medicines prescribed during care received in the SUS itself in the two weeks prior to the interview (2) and obtaining all the medicines, regardless of the source. Demographic and socioeconomic characteristics were included as independent variables. In 2019, 29.7% of the interviewees obtained all the prescribed medicines from the SUS, 81.8% obtained all the medicines in general (considering all sources), and 56.4% paid some amount for the medicines. The proportion who did obtain any medicine from the SUS and that made some out-of-pocket payment increased from 2013 to 2019. The likelihood of obtaining all the medicines in the SUS was higher among the poorest, and that of obtaining the medicines regardless of source was higher among the wealthiest. Approximately two out of three persons that were unable to access all the medicines reported difficulties obtaining them in services funded by the public sector. There was an increase in out-of-pocket expenditure on medicines in Brazil and a reduction in access through the SUS, among users of the system.

Universal healthcare coverage, patients' rights, and nurse-patient communication: a critical review of the evidence

The Sustainable Development Goals adopted by world leaders on September 25, 2015, aimed to end poverty and hunger, promote gender equity, empower women and girls, and ensure human dignity and equality by all human beings in a healthy environment. These development goals were premised on international human rights norms and institutions, thereby acknowledging the relevance of human rights in achieving each goal. Particularly, sustainable development goal 3, whose objective is to achieve universal health coverage, enhance healthy lives, and promote well-being for all, implicitly recognizes the right to health as crucial. Our focus in this paper is to discuss how promoting patients’ rights and enhancing effective nurse-patient communication in the healthcare setting is a significant and necessary way to achieve universal health coverage. Through a critical review of the empirical research evidence, we demonstrated that enhancing patients’ rights and effect nurse-patient communication will promote people-centered care, improve patients’ satisfaction of care outcomes, increase utilization of care services, and empower individuals and families to self-advocate for their health. These steps directly impact primary healthcare strategies and the social determinants of health as core components to achieving universal health coverage. We argue that without paying attention to the human rights dimensions or employing human rights strategies, implementing the other efforts will be inadequate and unsustainable in protecting the poorest and most vulnerable populations in the achievement of goal 3.

Quality assessment of cold chain storage facilities for regulatory and quality management compliance in a developing country context

BACKGROUND

Supply chain management is essential for cold chain medicines since they are temperature-controlled and must be maintained within a specific temperature range to ensure product integrity and quality. In Nigeria, guidelines that address drug distribution do not adequately address the issue of cold chain management in addition to challenges in implementation. Given the chaotic medicines distribution system, this study examined the quality of practice of supply chain management of cold chain products in line with the World Health Organisation's Expert Committee report on Specifications for Pharmaceutical Preparations.

METHODS

The study was set in Abuja Nigeria and descriptive survey was used to explore cold chain supply management. A checklist developed from regulatory requirements stipulated by the World Health Organisation covering documentations, storage and distribution guidelines was used to assess supply chain management of cold chain medicines across various facilities. Data were analysed using IBM Statistical Package for the Social Sciences (SPSS) version 25.

RESULTS

The results from this study showed that most of the storage facilities assessed (66.7%) did not meet up to the required standards of quality management for cold chain products. In addition, 50.4% of retail and hospital pharmacy facilities performed poorly in cold chain management practices. Many of aspects of quality management guidelines and regulations were not met by the facilities. Most facilities (66.7%) do not have their equipment calibrated, 43.6% of the hospital and retail pharmacies assessed do not have an automated system to cater for power failure while 37.6% do not perform a temperature check on cold chain products before receiving from suppliers.

CONCLUSION

The study has shown that the levels of the supply chain assessed for quality management and regulatory compliance performed poorly. There was limited availability and use of validated quality monitoring systems for cold chain medicines in these facilities.

Should COVID-19 Vaccines Authorized for Emergency Use Be Considered "Essential" Medicines?

A critical debate in the race to develop, market, and distribute COVID-19 vaccines could define the future of this pandemic: How much evidence demonstrating a vaccine's safety and efficacy should be required before it is considered "essential"? If a COVID-19 vaccine were to be designated an essential medicine by the World Health Organization, this would invoke special "core" human rights duties for governments to provide the vaccine as a matter of priority irrespective of resource constraints. States would also have duties to make the vaccine available in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at an affordable price. This question is especially critical and unique given that COVID-19 vaccines have in many cases been authorized for use via national emergency use authorization processes-mechanisms that enable the public to gain access to promising medical products before they have received full regulatory approval and licensure. In this paper, we examine whether unlicensed COVID-19 vaccines authorized for emergency use should ever be considered essential medicines, thereby placing prioritized obligations on countries regarding their accessibility and affordability.

An intersectional human rights approach to prioritising access to COVID-19 vaccines

We finally have a vaccine for the COVID-19 crisis. However, due to the limited numbers of the vaccine, states will have to consider how to prioritise groups who receive the vaccine. In this paper, we argue that the practical implementation of human rights law requires broader consideration of intersectional needs in society and the disproportionate impact that COVID-19 is having on population groups with pre-existing social and medical vulnerabilities. The existing frameworks/mechanisms and proposals for COVID-19 vaccine allocation have shortcomings from a human rights perspective that could be remedied by adopting an intersectional allocative approach. This necessitates that states allocate the first COVID-19 vaccines according to (1) infection risk and severity of pre-existing diseases; (2) social vulnerabilities; and (3) potential financial and social effects of ill health. In line with WHO’s guidelines on universal health coverage, a COVID-19 vaccine allocation strategy that it is more consistent with international human rights law should ensure that vaccines are free at the point of service, give priority to the worst off and be allocated in a transparent, participatory and accountable prioritisation process.

Universal access to essential medicines as part of the right to health: a cross-national comparison of national laws, medicines policies, and health system indicators

BACKGROUND

Access to essential medicines for the world's poor and vulnerable has made little progress since 2000, except for a few specific medicines such as antiretrovirals for HIV/AIDS. Human rights principles written into national law can create a supportive environment for universal access to medicines; however, systematic research and policy guidance on this topic is lacking.

OBJECTIVE

To examine how international human rights law and WHO's essential medicines policies are embedded in national law for medicines affordability and financing, and interpreted and implemented in practice to promote universal access to essential medicines.

METHODS

This thesis consists of (1) a cross-national content analysis of 192 national constitutions, 71 national medicines policies, and legislation for universal health coverage (UHC) from 16 mostly low- and middle-income countries; (2) a case study of medicines litigation in Uruguay, and (3) a follow-up report of eight right to health indicators for access to medicines from 195 countries.

RESULTS

Some, but not all, of the 12 principles from human rights law and WHO's policy are embedded in national UHC law and medicines policies (part 1). Even the most rights-compliant legislation for access to medicines is subject to the unique and inconsistent interpretation of domestic courts, which may be inconsistent with the right to health in international law (part 2). Many national health systems for which data were available still fail to meet the official targets for eight indicators of access to medicines (part 3).

CONCLUSIONS

International human rights law and WHO policy are embedded in national law for essential medicines and practically implemented in national health systems. Law makers can use these findings and the example texts in this thesis as a starting point for writing and monitoring governments' rights-based legal commitments for access to medicines. Future research should study the effect of national law on access to medicines and population health.

Essential Medicines in Universal Health Coverage: A Scoping Review of Public Health Law Interventions and How They Are Measured in Five Middle-Income Countries

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated.

Pharmaceutical patents: reconciling the human right to health with the incentive to invent

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Drug discovery is exciting and transformative but conflicts exist between the incentive to invent and the rights of others to access medicines

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Tensions between fundamental rights to access essential medicines and rights of the inventor and investors are considered

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Effective incentives to innovate in developed countries can lead to global improvements in access to medicine if the intellectual property system is calibrated to permit this

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Compulsory licensing and alternative mechanisms facilitating global access to drugs in the context of rights to the highest attainable standard of health and intellectual property are also discussed

In developed countries that protect core aspects of the fundamental human right to the highest attainable standard of health, how does that right intersect with intellectual property rights? Here, the human rights implication of providing access to all cancer drugs recommended by experts in a developed country is considered in the context of conflict between the incentive to invent and the rights of others to access medicines. Effective incentives to innovate in developed countries can lead to global improvements in access to medicine if the intellectual property system is calibrated to permit this. This depends partly on the usefulness of compulsory licensing and alternative mechanisms facilitating global access to drugs. This review considers tensions between fundamental rights to access essential medicines and rights of the inventor and investors, including the pharmaceutical industry.