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How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study.

ABSTRACT: Performance-based financing (PBF) is being implemented across low- and middle-income countries to improve the availability and quality of health services, including medicines. Although a few studies have examined the effects of PBF on the availability of essential medicines (EMs) in low- and middle-income countries, there is limited knowledge of the mechanisms underlying these effects. Our research aimed to explore how PBF in Cameroon influenced the availability of EMs, and to understand the pathways leading to the experiential dimension related with the observed changes. The design was an exploratory qualitative study. Data were collected through in-depth interviews, using semi-structured questionnaires. Key informants were selected using purposive sampling. The respondents (n?=?55) included health services managers, healthcare providers, health authorities, regional drugs store managers and community members. All interviews were recorded, transcribed and analysed using qualitative data analysis software. Thematic analysis was performed. Our findings suggest that the PBF programme improved the perceived availability of EMs in three regions in Cameroon. The change in availability of EMs experienced by stakeholders resulted from several pathways, including the greater autonomy of facilities, the enforced regulation from the district medical team, the greater accountability of the pharmacy attendant and supply system liberalization. However, a sequence of challenges, including delays in PBF payments, limited autonomy, lack of leadership and contextual factors such as remoteness or difficulty in access, was perceived to hinder the capacity to yield optimal changes, resulting in heterogeneity in performance between health facilities. The participants raised concerns regarding the quality control of drugs, the inequalities between facilities and the fragmentation of the drug management system. The study highlights that some specific dimensions of PBF, such as pharmacy autonomy and the liberalization of drugs supply systems, need to be supported by equity interventions, reinforced regulation and measures to ensure the quality of drugs at all levels.

SUBMITTER: Sieleunou I

PROVIDER: S-EPMC6901074 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study.

Sieleunou Isidore I Turcotte-Tremblay Anne-Marie AM De Allegri Manuela M Taptué Fotso Jean-Claude JC Azinyui Yumo Habakkuk H Magne Tamga Denise D Ridde Valéry V

Health policy and planning 20191201 Supplement_3

Performance-based financing (PBF) is being implemented across low- and middle-income countries to improve the availability and quality of health services, including medicines. Although a few studies have examined the effects of PBF on the availability of essential medicines (EMs) in low- and middle-income countries, there is limited knowledge of the mechanisms underlying these effects. Our research aimed to explore how PBF in Cameroon influenced the availability of EMs, and to understand the pat ...[more]

PMID: 31816071

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Project description:Access to safe, effective, and affordable essential medicines (EM) is critical to quality health services and as such has played a key role in innovative health system strengthening approaches such as Performance-based Financing (PBF). Available literature indicates that PBF can improve EM availability, but has not done so consistently in the past. Qualitative explorations of the reasons are yet scarce. We contribute to expanding the literature by estimating the impact of PBF on EM availability and stockout in Burkina Faso and investigating mechanisms of and barriers to change. The study used an explanatory mixed methods design. The quantitative study component followed a quasi-experimental design (difference-in-differences), comparing how EM availability and stockout had changed three years after implementation in 12 PBF and in 12 control districts. Qualitative data was collected from purposely selected policy and implementation stakeholders at all levels of the health system and community, using in-depth interviews and focus group discussions, and explored using deductive coding and thematic analysis. We found no impact of PBF on EM availability and stockouts in the quantitative data. Qualitative narratives converge in that EM supply had increased as a result of PBF, albeit not fully satisfactorily and sustainably so. Reasons include persisting contextual challenges, most importantly a public medicine procurement monopoly; design challenges, specifically a disconnect and disbalance in incentive levels between service provision and service quality indicators; implementation challenges including payment delays, issues around performance verification, and insufficient implementation of activities to strengthen stock management skills; and concurrently implemented policies, most importantly a national user fee exemption for children and pregnant women half way through the impact evaluation period. The case of PBF and EM availability in Burkina Faso illustrates the difficulty of incentivizing and effecting holistic change in EM availability in the presence of strong contextual constraints and powerful concurrent policies.

Project description:BackgroundHaiti is the poorest country in the Western Hemisphere and faces numerous challenges, including inadequate medication access for its residents. The objective of this study was to determine the availability, prices, and affordability of essential medicines in Haiti and compare these findings to other countries.MethodsWe conducted a cross-sectional nationwide survey in 2011 of availability and consumer prices of 60 essential medicines in Haiti using a standardized methodology developed by the World Health Organization and Health Action International. The survey was conducted in 163 medicine outlets in four health care sectors (public, retail, nonprofit and mixed sectors). Medicine prices were expressed as ratios relative to the International Reference Price. Affordability was calculated by comparing the costs of treatment for common conditions with the salary of the lowest paid government worker and was compared to available data from four Latin American countries.ResultsFor generic medicines, the availability in public, retail, nonprofit and mixed sectors was 20%, 37%, 24% and 23% of medications, respectively. Most of the available medicines were priced higher than the International Reference Price. The lowest paid government worker would need 2.5 days' wages to treat an adult respiratory infection with generic medicines from the public sector. For treatment of common conditions with originator brands (OB) purchased from a retail pharmacy, costs were between 1.4 (anaerobic bacterial infection) and 13.7 (hyperlipidemia) days' wages, respectively. Treatment of pediatric bacterial infections with the OB of ceftriaxone from a retail pharmacy would cost 24.6 days' wages. Prices in Bolivia, Colombia, Mexico and Nicaragua were frequently lower for comparable medications.ConclusionsThe availability of essential medicines was low and prices varied widely across all four sectors. Over 75% of Haitians live on less than US$ 2.00 /day; therefore, most medication regimens are largely unaffordable. Inclusion of essential medications on the national formulary and working with organizations responsible for importing medications into Haiti, particularly drug donation agencies, are important first steps to increasing medication access.

Project description:IntroductionThe Malawian government recently introduced cost-covering consultation fees for self-referral patients in tertiary public hospitals. Previously, patients received medicines free of charge in government-owned health facilities, but must pay elsewhere. Before the government implements a payment policy in other areas of health care, it is important to investigate the prices, affordability and availability of essential medicines in Malawi.MethodsData on availability and prices of 50 essential medicines were collected in 44 health facilities in two major cities and two districts. These included 12 public facilities, 11 facilities of the Christian Health Association of Malawi (CHAM), nine retail pharmacies, eight wholesalers and four private clinics/hospitals. Price, availability and affordability were assessed based on the methodology developed by the World Health Organization and Health Action International, which compares local prices to international reference prices.Results and discussionThe overall availability of medicines was 48.5% in public facilities, 71.1% in retail pharmacies, 62.9% in CHAM facilities and 57.5% in private clinics. The availability of essential medicines varied from 0% for ethosuximide to 100% for amoxicillin and cotrimoxazole tablets. Antibiotic formulations for adults were widely available, in contrast to the low availability of pediatric formulations. Several medicines for non-communicable diseases like sodium valproate, phenytoin, paraldehyde, captopril and simvastatin showed poor availability and affordability. The overall median price ratio compared to the international reference price was 1.11 for wholesalers, 2.54 in CHAM facilities, 2.70 in retail pharmacies, and 4.01 in private clinics, which is low compared to other countries. But nevertheless, for 18 out of 32 medicines assessed, the cost of one course exceeded the statutory minimum daily wage, making them unaffordable to a majority of the population. Therefore, continued provision of free public health care is still of critical importance for the foreseeable future until other financing mechanisms have been explored.

Project description:IntroductionAccess to essential medicines (EMs) is a basic human right. Non-availability and shortages of EMs are reported for Pakistan but there is insufficient data to define the nature and magnitude of this problem. The current study is designed to systematically analyze the medicines included in the National Essential Medicines List (NEML) for their availability through comprehensive document analysis.MethodsAn expanded list of medicinal items was developed using the NEML of Pakistan (2018) to enlist individual medicines with their specifications. Registration status of the medicines was searched using three publicly accessible information sources; Pharmaguide 25th Edition, 2018-19, the on-line Drug Information System, and the Mobile Application Pharmapedia followed by a later 3-step validation of the data. The unregistered EMs were then further categorized into three subgroups in accordance with their possible remedial strategies.FindingsThe 19 studied categories comprised 690 EMs and it was found that 179 (26%) of these EMs don not have a registration status. However, it was also identified that the availability of 47 (26.2%) out of 179 unregistered EMs can be enssured by strengthening compounding services, and prioritizing registration of age-appropriate formulations. Availability of another 39 (21.7%) such medicines can be ensured by revising the NEML or the product registrations for the slight differences in their different specifications. The categories showing high proportion of unregistered medicines included anti-Parkinson's medicines (100%), antidotes and other substances used in poisoning (60%), diuretics (47%), anticonvulsants/antiepileptics (42%), hormones and other endocrine medicines and contraceptives (38%), medicines for mental and behavioral disorders (30%), anti-infectives (27%), medicines for pain and palliative care (26%), medicines for neonatal care (25%), medicines for diseases of joint (25%), gastrointestinal medicines (24%) and cardiovascular medicines (15%).ConclusionThe study shows the absence of registration status of a significant number of EMs in Pakistan. This could be major barrier in their access. Strategies are needed to strengthen the processes of their registration on priority basis.

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How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study.

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How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study.

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