The impact of pharmaceutical tendering on prices and market concentration in South Africa over a 14-year period.

OBJECTIVE: We investigated the South African tendering system for medicines to (a) evaluate its impact on prices and market concentration over a 14-year period and (b) analyze the accuracy of government forecasts of drug demand. METHODS: We calculated Herfindahl-Hirschman indexes to measure market concentration levels based on all pharmaceutical tender contracts issued by the South African government between 2003 and 2016 (n = 8701). We estimated price indexes to track changes in medicine costs over this period. We compared prices set through tenders in the public health care system to the corresponding prices in the private system. We also analyzed government data on procurement in selected drug classes to assess the accuracy of demand forecasts. FINDINGS: Between 2003 and 2016, the prices of medicines in most tender categories in the public health care system dropped by an average of around 40% or more. The prices of medicines procured for the public system through tenders were almost always lower than those sold in the private system. Tenders generally remained moderately to highly competitive over time (i.e., Herfindahl-Hirschman indexes < 2500), although the number of different firms winning contracts decreased in many categories. There were large discrepancies between the drug need estimates by the government and the quantities it went on to procure, with estimates off by more than 50% in most drug classes (9/16 observations). CONCLUSION: Tendering may be an effective measure to lower drug costs. Because most tenders remained competitive over time, price decreases may be durable. South African government officials should monitor the availability and prices of medicines to ensure continued access to affordable medicines for patients, as it may be undermined by the decreasing number of firms winning contracts over time. Given the large discrepancy between forecasts and procurements, the government would benefit from improving the accuracy of its demand forecasts.

Conversations worth having: the perceived relevance of advance care planning among teachers, hospice staff, and pastors in Knysna, South Africa.

BACKGROUND: Little is known about the relevance of advance care planning (ACP), including the use of advance directives (AD) and health care power of attorney in transitional countries where access to health care is often limited. OBJECTIVE: The study's objective was to determine the perceived relevance of ACP amongst select groups in the South African community, and to refine an existing tool for initiating conversations on the topic. DESIGN: Five focus groups were recruited, with a total of 51 participants, including pastors, hospice staff, teachers, and community caregivers. METHODS: The concept of ACP was introduced. Participants reflected on its relevance, how best to approach the topic, and what aspects ACP should cover. Participants also evaluated an existing tool for initiating conversations about ACP, with their respective communities in mind. RESULTS: There was broad recognition of the unexplored benefit of ACP, as well as barriers to initiating conversations. Respondents agreed that ACP should take place before a health crisis; individual, cultural, and contextual factors were identified as factors influencing who should initiate conversations, and what to discuss. Specific factors included involving family decision makers in ACP and preferences for place of death and place of care. There was a strong wish for choices to be acted on, and participants felt advocacy was needed to improve public knowledge of the role of ACP and ADs. CONCLUSION: ACP is deemed relevant and helpful in this South African context. Factors for consideration include sensitivity to diverse cultural and individual preferences, available resources to meet preferences, wider participation in discussion among collectivist-oriented societies, and the role of gender in family decision making.