A systematic scoping review of medicine availability and affordability in Africa.

BACKGROUND: The most recent World Medicines Situation Report published in 2011 found substantial medicine availability and affordability challenges across WHO regions, including Africa. Since publication of the 2011 report, medicine availability and affordability has risen on the international agenda and was included in the Sustainable Development Goals as Target 3.8. While numerous medicine availability and affordability studies have been conducted in Africa since the last World Medicines Situation Report, there has not been a systematic analysis of the methods used in these studies, measures of medicine availability and affordability, categories of medicines studied, or geographic distribution. Filling this knowledge gap can help inform future medicine availability and affordability studies, design systems to monitor progress toward Sustainable Development Goal Target 3.8 in Africa and beyond, and inform policy and program decisions to improve medicine availability and affordability. METHODS: We conducted a systematic scoping review of studies assessing medicine availability or affordability conducted in the WHO Africa region published from 2009-2021. RESULTS: Two hundred forty one articles met our eligibility criteria. 88% of the articles (213/241) reported descriptive studies, while 12% (28/241) reported interventional studies. Of the 198 studies measuring medicine availability, the most commonly used measure of medicine availability was whether a medicine was in stock on the date of a survey (124/198, 63%). We also identified multiple other availability methods and measures, including retrospective stock record reviews and self-reported medicine availability surveys. Of the 59 articles that included affordability measures, 32 (54%) compared the price of the medicine to the daily wage of the lowest paid government worker. Other affordability measures were patient self-reported affordability, capacity to pay measures, and comparing medicines prices with a population-level income standard (such as minimum wage, poverty line, or per capita income). The most commonly studied medicines were antiparasitic and anti-bacterial medicines. We did not identify studies in 22 out of 48 (46%) countries in the WHO Africa Region and more than half of the studies identified were conducted in Ethiopia, Kenya, Tanzania, and/or Uganda. CONCLUSION: Our results revealed a wide range of medicine availability and affordability assessment methodologies and measures, including cross-sectional facility surveys, population surveys, and retrospective data analyses. Our review also indicated a need for greater focus on medicines for certain non-communicable diseases, greater geographic diversity of studies, and the need for more intervention studies to identify approaches to improve access to medicines in the region.

The role of government agencies and other actors in influencing access to medicines in three East African countries.

The WHO Model List of Essential Medicines (MLEM) has since 1977 helped prioritize and ensure availability of medicines especially in low- and middle-income countries. The MLEM consists mainly of generic medicines, though recent trends point towards listing expensive on-patent medicines and increasing global support for medicines against non-communicable diseases. However, the implications of such changes for national essential medicines list (NEML) updates for access to essential medicines has received relatively little attention. This study examined how government agencies and other actors in Kenya, Uganda and Tanzania participate in and influence the NEML update process and subsequent availability of prioritized medicines; and the alignment of these processes to WHO guidance. A mixed study design was used, with qualitative documentary review, key informant interviews and thematic data analysis. Results show that NEML updating processes were similar amongst the three countries and aligned to WHO guidelines, albeit conducted irregularly, with tendency to reprioritization during procurement stages, and were not always accompanied by revision of clinical guidelines. Variations were noted in the inclusion of medicines against cancer and hepatitis C, and the utilization of health technology assessment (HTA). For medicines against diseases with high global engagement, such as HIV/AIDS and TB, national stakeholders had more limited inputs in prioritization and funding. Furthermore, national actors were not influenced by the pharmaceutical industry during the NEML update process, nor were any conflicting agendas identified between health, trade and industrial policies. Hence, the study suggests that more attention should be paid to the combination of HTAs and NEMLs, particularly as countries work towards universal health coverage, in addition to heightened awareness of how global disease-specific initiatives may confound national implementation of the NEML. The study concludes with a call to strengthen country-level policy and procedural coherence around the process of prioritizing and ensuring availability of essential medicines.

A political economy analysis of human resources for health (HRH) in Africa.

BACKGROUND: Despite a global recognition from all stakeholders of the gravity and urgency of health worker shortage in Africa, little progress has been achieved to improve health worker coverage in many of the African human resources for health (HRH) crisis countries. The problem consists in how policy is made, how leaders are accountable, how the World Health Organization (WHO) and foreign donors encourage (or distort) health policy, and how development objectives are prioritized in these countries. METHODS: This paper uses political economy analysis, which stems from a recognition that the solution to the shortage of health workers across Africa involves more than a technical response. A number of institutional arrangements dampen investments in HRH, including a mismatch between officials' tenure in office and program results, the vertical nature of health programming, the modalities of Overseas Development Assistance (ODA) in health, the structures of the global health community, and the weak capacity in HRH units within Ministries of Health. A major change in policymaking would only occur with a disruption to the political or institutional order. RESULTS/CONCLUSIONS: The case study of Ethiopia, who has increased its health workforce dramatically over the last 20 years, disrupted previous institutional arrangements through the power of ideas-HRH as a key intermediate development objective. The framing of HRH created the rationale for the political commitment to HRH investment. Ethiopia demonstrates that political will coupled with strong state capacity and adequate resource mobilization can overcome the institutional hurdles above. Donors will follow the lead of a country with long-term political commitment to HRH, as they did in Ethiopia.

The Code of Practice and its enduring relevance in Europe and Eastern and Southern Africa.

BACKGROUND: The relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Personnel will be reviewed by the World Health Assembly in 2015. The origins of the Code of Practice and the global health diplomacy process before and after its adoption are analyzed herein. METHODS AND RESULTS: Case studies from the European and eastern and southern African regions describe in detail successes and failures of the policy implementation of the Code. In Europe, the Code is effective and even more relevant than before, but might require some tweaking. In Eastern and Southern Africa, the code is relevant but far from efficient in mitigating the negative effects of health workforce migration. CONCLUSIONS: Solutions to strengthen the Code include clarification of some of its definitions and articles, inclusion of a governance structure and asustainable and binding financing system to reimburse countries for health workforce losses due to migration, and featuring of health worker migration on global policy agendas across a range of institutional policy domains.

Health worker migration from South Africa: causes, consequences and policy responses.

BACKGROUND: This paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries-Jamaica, India, the Philippines, and South Africa-have historically been "sources" of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa. METHODS: The study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically. RESULTS: There has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself. CONCLUSIONS: In the near past, South Africa's health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa.

Factors influencing treatment outcomes in tuberculosis patients in Limpopo Province, South Africa, from 2006 to 2010: A retrospective study.

BACKGROUND: South Africa has a high burden of tuberculosis (TB), with high human immunodeficiency virus (HIV)-TB co-infection rates and the emergence of multidrugresistant TB. OBJECTIVES: To describe treatment outcomes and factors influencing outcomes amongst pulmonary TB (PTB) patients in the Limpopo Province. METHOD: A retrospective review was conducted of data on the provincial electronic TB register (ETR.net) for the years 2006 to 2010 (inclusive), and a random sample of 1200 records was selected for further analysis. The Chi square test was used to examine the influence of age, gender, health facility level, diagnostic category and treatment regimen on treatment outcomes. RESULTS: Overall 90 617 (54.6% male) PTB patients were registered between 2006 and 2010. Of the sampled 1200 TB cases, 72.6% were in persons aged 22 to 55 years and 86.2% were new cases. The TB mortality rate was 13.6% (much higher than the World Health Organization target of 3%), whilst the default rate was 9.8%. There was a strong association between age (P < 0.001), diagnostic category (P < 0.001), treatment regimen (P < 0.001), and health facility level (P < 0.001) and treatment outcome. Those aged 22­55, and 56­74 years were more likely to die (P < 0.05). Poor treatment outcomes were also associated with initial treatment failure, receiving treatment at hospital and treatment regimen II. CONCLUSION: The poor TB treatment outcomes in Limpopo, characterised by a high mortality and default rates, call for strengthening of the TB control programme, which should include integration of HIV and/or AIDS and TB services.

Mortality associated with tuberculosis/HIV co-infection among patients on TB treatment in the Limpopo province, South Africa.

BACKGROUND: South Africa has a high tuberculosis burden, and Limpopo Province experienced higher than national average TB mortality rates between 1997 and 2008. OBJECTIVE: To establish factors associated with TB mortality in Limpopo Province in 2008. DESIGN: Retrospective study using provincial data for patients who died after commencing TB treatment between 01 January 2008 and 31 December 2008. RESULTS: In 2008, some 18074 patients started treatment: 15995 (88.5%) had pulmonsry TB (PTB), while 2079 (11.5%) had Extra pulmonary TB (EPTB). Overall, 2242 (12.4%) patients died, mainly PTB patients (n=1906; 85%), more males (n=1159, 51.7%), mainly those aged 25 to 54 years (n=1749, 78.0%), and new cases (1914; 85.4%). TB mortality was significantly higher among smear negative than smear positive patients (17% vs 13.8%; P<0.001), among those with EPTB compared to PTB patients (P<0.001), and among re-treatment cases (P<0.001). Only 4237 (23.4%) patients had HIV status known, with higher mortality found among HIV positive than the HIV negative patients (P<0.0001); but HIV status was not known for the majority who died (n=1685, 75.2%). CONCLUSION: Higher mortality was associated with age 22-55 years; smear negativity, EPTB, HIV infection, and re-treatment. The findings call for greater integration of TB control efforts and HIV services, especially among the 22-55 year age group.

Foreign advertisements for doctors in the SAMJ 2006 - 2010.

BACKGROUND: There is much concern about the migration of health professionals from developing countries, and the contribution of active recruitment to the phenomenon. One active recruitment strategy is advertisements in professional journals and other media. OBJECTIVE: To establish the trends in foreign advertisements for doctors placed in the South African Medical Journal (SAMJ) from January 2006 to December 2010. METHODS: A retrospective review was conducted of 60 issues of the SAMJ published in the preview years. Printed journals were scanned for foreign advertisements. The findings were compared with a review of 2000 - 2004 in the same journal. RESULTS: There were 1 176 foreign advertisements placed in the SAMJ in the review period, reducing from 355 in 2006 to 121 in 2010. The countries placing the most advertisements were Australia (n=428, 36.4%), Canada (n=286, 24.3%), New Zealand (n=191, 16.2%) and the UK (n=108, 9.2%). Compared with the earlier findings, there was a reduction in advertisements for the top countries, excepting Australia. The top 4 countries remained the same for the 2 review periods, but the order changed, with Australia superseding the UK. CONCLUSION: The number of foreign advertisements placed in the SAMJ declined over the period under review, and there was a change in ranking of the top 4 advertising countries. These findings are discussed from the perspective of global human resources for health initiatives.

Policy and programmatic implications of task shifting in Uganda: a case study.

BACKGROUND: Uganda has a severe health worker shortage and a high demand for health care services. This study aimed to assess the policy and programmatic implications of task shifting in Uganda. METHODS: This was a qualitative, descriptive study through 34 key informant interviews and eight (8) focus group discussions, with participants from various levels of the health system. RESULTS: Policy makers understood task shifting, but front-line health workers had misconceptions on the meaning and intention(s) of task shifting. Examples were cited of task shifting within the Ugandan health system, some formalized (e.g. psychiatric clinical officers), and some informal ones (e.g. nurses inserting IV lines and initiating treatment). There was apparently high acceptance of task shifting in HIV/AIDS service delivery, with involvement of community health workers (CHW) and PLWHA in care and support of AIDS patients.There was no written policy or guidelines on task shifting, but the policy environment was reportedly conducive with plans to develop a policy and guidelines on task shifting.Factors favouring task shifting included successful examples of task shifting, proper referral channels, the need for services, scarcity of skills and focused initiatives such as home based management of fever. Barriers to task shifting included reluctance to change, protection of professional turf, professional boundaries and regulations, heavy workload and high disease burden, poor planning, lack of a task shifting champion, lack of guidelines, the name task shifting itself, and unemployed health professionals.There were both positive and negative views on task shifting: the positive ones cast task shifting as one of the solutions to the dual problem of lack of skills and high demand for service, and as something that is already happening; while negative ones saw it as a quick fix intended for the poor, a threat to quality care and likely to compromise the health system. CONCLUSION: There were widespread examples of task in Uganda, and task shifting was mainly attributed to HRH shortages coupled with the high demand for healthcare services. There is need for clear policy and guidelines to regulate task shifting and protect those who undertake delegated tasks.

Profile and career preferences of pharmacy students at the University of Limpopo, Turfloop Campus, South Africa.

CONTEXT: There is a maldistribution of pharmacists in the South African health system, with only 15.6% of pharmacists working in the public sector, while the public sector serves more than 80% of the population. SETTING: University of Limpopo, Turfloop Campus, Pharmacy Programme. OBJECTIVE: To establish the profile and career preferences of University of Limpopo pharmacy students and investigate factors likely to influence their choices. DESIGN: Cross-sectional descriptive study of Bachelor of Pharmacy students, using a semi-structured questionnaire. FINDINGS: The response rate was 93% (157/169), with 44% female and 69% between the ages of 21 to 25 years. Nearly 80% of respondents were of rural origin; 77% attended rural government schools, 18% urban government schools, and 4% attended private schools. Only 39% of students indicated pharmacy as their first choice and 47% as second choice. Forty-six percent of the responding students preferred to work in a government hospital, 36% in industry, and 7%, 6% and 3% in private hospitals, the retail sector and academia, respectively. About 40% indicated a preference to work in rural areas. Most of the students stated service to community and paying back their sponsor as their main reasons for government hospital preference. Money, in combination with other reasons (e.g., working conditions), influenced work sector preference for less than 15% of responding students - with non-monetary incentives apparently more influential in student public sector preferences. CONCLUSIONS: Most University of Limpopo pharmacy students intend to work in rural areas and the public sector, and are mainly motivated by the need to serve the community.

Career intentions of UNITRA medical students and their perceptions about the future.

CONTEXT: The University of Transkei (UNITRA) medical programme follows a problem-based learning and community-based education curriculum. OBJECTIVE: To gauge the views of UNITRA medical students about their future, and their career intentions. DESIGN: A semi-structured questionnaire on intentions to specialize or not, preferred place of work, overall view of the future, and careers guidance. FINDINGS: The questionnaire was completed by 364 students (87.7% response rate). The sector preferences are 82.3% public, 6.8% university and 10.9% private. Place of work preferences are urban (37%), rural (27%), city (12%) and abroad (8%), while 16% have no preference. Rural preference varies from 48.5% among 1st year students to 5.9% among 6th year students, while urban preference are 26.2% for Year I and 64.7% for Year VI students. 89.8% of respondents intended to specialize, mainly in clinical fields, with the most influential factors in the choice of specialty being interest and challenge. Most students (78%) view the future positively, 13% say it is uncertain, 8% have no idea about the future; and 1% think the future is negative. Frequent reasons cited for a bright future are job-related, personal attitude, sense of achievement, and the type of training. Most students have received little or no career guidance and would like such topics in the curriculum. CONCLUSION: UNITRA medical students are optimistic about the future. The majority intend to stay in South Africa and work in the public sector, and most of them wish to pursue clinical specialties.