Exploring the Essential Medicines List Concept

Background: Access to medicines is a basic human right. The World Health Organization (WHO) Model List of Essential Medicines was created in 1977, to promote access to essential medicines that satisfy the priority health care needs of the population. In this day and age, access to safe and affordable medicines is not guaranteed to all. There exists global inequality of access to lifesaving or essential medicines. This is referred to by the WHO as the ‘global drug gap’, in which approximately one third of the global population still does not have access to basic medicines. Contributing to the disparity in access, are rising pharmaceutical expenditures and globalisation of complex pharmaceutical supply chain networks. This has resulted in countries of all economies and geographical regions sourcing their medicines from common sources. Therefore, challenges accessing unavailable medicines have become a shared experience, as demonstrated by the relatively recent emergence and recurrence of global drug shortage crises. The WHO framework for access to essential medicines, which considers rational selection of medicines, affordable prices, sustainable financing, and reliable health and supply systems, was used as a theoretical framework to explore the gap in access to medicines. Aims and Objectives: Aim: To explore stakeholder views about the concept of essential medicines. Objectives: (1) To explore the application of the Essential Medicines List (EML) concept and how this was associated with access to essential medicines. (2) To explore the factors that influence access to essential medicines, and understand the roles of international key stakeholders involved in this process. (3) To explore what constitutes an “essential” medicine, and how the EML concept functions in a high income country (HIC) context. Content of This Thesis This thesis is made up of 4 chapters. Chapter 1 contains the background and a review of the literature on access to essential medicines. The challenges identified in chapter 1 lead to the exploration of global perspectives on the supply and management of essential medicines in chapter 2. The qualitative study in chapter 3 describes what constitutes an essential medicine for stakeholders in a high income country (HIC). Lastly, chapter 4 contains general discussions and conclusions from the work described in this thesis. Methods: A narrative literature review (chapter 1) was performed to explore how the application of the EML concept is associated with access to essential medicines. A search strategy developed from the principles of the WHO access to medicines framework was used to identify primary studies from Medline, Embase and PubMed. A qualitative study was conducted to explore perspectives of international (chapter 2) and Australian (chapter 3) key stakeholders about the pharmaceutical supply chain, on the application and relevance of EML concept and what makes a medicine essential. Snowball sampling was used to recruit decision makers, leaders or senior managers involved in medicines decision making across seven stakeholder groups. Stakeholders included: government, health care providers, academics, consumer groups, non-profit organisations, pharmaceutical manufacturers and wholesaler/distributors. Forty-seven semi structured interviews were conducted face-to-face, via Skype or telephone, audio-recorded and transcribed verbatim. Interviews were conducted until thematic saturation was achieved. Data were analysed using a grounded theory approach. The comprehensive theory of collaboration was applied after the grounded theory analysis to organise and understand results within a management context. In addition, chapter 2 used the Ishikawa fishbone diagram to illustrate the complexities of the pharmaceutical supply chain. Meanwhile, chapter 3 illustrated the conceptual model derived from the results. Key Findings: Chapter 1- A literature review showed that there has been improved access to essential medicines for many populations. Findings showed EMLs help promote advocacy and provide reliable evidence at the health systems level. However, there was variable use of EMLs at the health services delivery level (i.e. for a patient at the point of care). Decision making around standard treatment guidelines and EMLs were often not aligned with procurement and management strategies within the supply chain. The literature review showed that accessing medicines was complex. Studies were often not well-designed, had narrow research objectives and few qualitative studies were conducted. Studies focused on resource limited settings in LMICs and scarce data was available for EMLs in HICs. Chapter 2- Qualitative interviews with international stakeholders described the complexities involved in managing the global pharmaceutical supply chain. While stakeholders’ roles and responsibilities were inter-connected, therapeutic decision making was often separated from logistic management of the pharmaceutical supply chain due to potential conflicts of interest. This created many gaps and inconsistencies around pricing and costs, planning and reactivity, communication and transparency, and contributed to difficulties building trust and consistency between stakeholders. Adding to this complexity, individualised or patient-centred care approaches have emphasised the need for consumer choice and demand a wide range of products that has become increasingly challenging to manage. Therefore, drug shortages have highlighted the opportunity for collaborative alliances to identify, prioritise, and manage vulnerabilities in the supply chain to prevent or mitigate patient harm as a result of restricted access to medicines. In particular, wholesalers and distributors were identified as potentially having more valuable roles in managing supply disruptions (e.g. redistribution) and facilitating information exchange between stakeholders (e.g. forecasting or confirming at what level of the system a shortage occurs). Participants also suggested designating drug shortage experts or liaison to manage and communicate shortages, especially to consumers and health providers. Chapter 3- Qualitative interviews with Australian stakeholders demonstrated that the different perceived functions of EMLs seemed to be stratified depending on whether the decision making context was at a health systems level or at an individual level (i.e., for a patient at the point of care). EMLs can function as reimbursement lists at the health systems level, or hospital formularies at the health services level. Meanwhile, non-reimbursed or off-formulary medicines were available to consumers who were willing and able to pay if they were deemed essential to individuals. Conversely, some medicines can be deemed essential but were not available or affordable to individuals. The wide range of views in this study, highlight the complexities of decision-making processes involved in developing and managing EMLs, which has been compounded by the expanding consumer need to have a range of therapeutic options. These findings emphasise the context within the health system determines for whom a medicine is deemed essential. Conclusion: Prior to this thesis, EMLs have been studied with narrow research objectives and mainly in LMICs. This body of research was the first to explore how the application and management of EMLs effected access to medicines, from a broad range of stakeholder views involved in both therapeutic decision making and logistics management. Furthermore, it was also a rare study that examined the EML concept within HIC contexts. Findings from this body of work demonstrated different perceived functions of the EML. Furthermore, it also questioned whether the term ‘essential’ was appropriate and reflected how the EML was used. While EMLs can be useful to guide evidence based decision making for reimbursement at the systems level, the variations in the notion of essential at the individual level is influenced by an individual’s choice. Therefore, this highlights the importance of guiding (or limiting) consumer choice with appropriate and accessible information, to help individuals make informed and responsible decisions. This research confirmed that the access to medicines gap continues to be problematic. The pharmaceutical supply chain has been unable to handle drug shortages adequately. Therefore, in order to sustain patient-centred care practices, concessions by all stakeholders must be made if the supply chain is to withstand global economic, political, and ecological instability. Multi-stakeholder engagement, transparent processes, innovative communication pathways, and EML approaches offer potential solutions to mitigate supply chain disruptions. Future approaches should align decision making priorities with procurement practices. Decision makers and supply chain managers have a valuable opportunity to reflect and understand how the current system is functioning, in order to develop foundations for improved processes, and innovative and cooperative platforms to interact and network

EFFECTS OF EXTENSIVE READING ON EFL LEARNERS’ WRITING PERFORMANCE

Extensive Reading (ER) is considered as a good learning technique to enhance every skill in language learning. It is considered to assist the improvement of other skills of language learners especially English as a Foreign Language (EFL) leaners. This study is designed to evaluate the effectiveness of ER on EFL learners’ writing performance and to identify the EFL learners’ attitude towards the effects of ER on writing performance. The study recruited a group of 59 non-English majors at a public university in Vietnam. The participants were divided into two groups, i.e., experimental group and control group. The participants in the experimental group were assigned extensive reading materials as their homework to support their learning of writing meanwhile the participants in the control group were guided to write without the support of extensive reading materials. To check the differences of the participants’ writing ability before and after the intervention, pre-test and post-test were employed. A questionnaire was also delivered to the experimental group after the treatment. The results from the tests revealed that ER supported EFL learners in their writing performance. The experimental group had more significant enhancement. The results obtained from the questionnaire also indicated that the EFL learners had positive attitudes towards the use of extensive reading materials provided in their writing learning process.   Article visualizations

FRESHMAN EFL LEARNERS’ ANXIETY IN SPEAKING CLASSES AND COPING STRATEGIES

This study aims to investigate what speaking anxiety freshman EFL learners encountered in their classes and what strategies they used to reduce their anxiety. A mixed methods approach was employed to collect the data, including a questionnaire following the quantitative method and individual semi-structured interviews following the qualitative method. The participants were 185 freshman EFL learners at several universities in the Mekong Delta. The combination of the Foreign Language Classroom Anxiety Scale developed by Horwitz, Horwitz & Cope (1986) and the theories about three kinds of anxiety proposed by Ellis (1994) was adapted to measure freshman EFL learners’ kinds of speaking anxiety in classes. Additionally, the five categories of coping strategies in Kondo and Ling (2004) were adapted to measure the participants’ coping strategies for reducing their speaking anxiety. The results of the study showed that the participants encountered all three kinds of speaking anxiety including trait anxiety, specific-situation anxiety, and state anxiety in classes. Furthermore, the study also indicated five kinds of strategies utilized by the participants to reduce their anxiety in speaking class namely preparation strategies, relaxation strategies, positive thinking strategies, peer-seeking strategies, and resignation strategies. From the results, it was also indicated that preparation strategies were used more frequently than the other strategies by the participants in speaking classes.  Article visualizations

Meta-analysis of driving behavior studies and assessment of factors using structural equation modeling

The aim of this paper is to understand the factors that influence unsafe driving practices by examining published studies that utilized the Theory of Planned Behavior (TPB) to predict driving behavior. To this end, it reviews 42 studies published up to the end of 2021 to evaluate the predictive utility of TPB by employing a meta-analysis and structural equation model. The results indicate that these studies sought to predict 20 distinct driving behaviors (e.g., drink-driving, use of cellphone while driving, aggressive driving) using the original TPB constructs and 43 additional variables. The TPB model with the three original constructs is found to account for 32% intentional variance and 34% behavioral variance. Among the 43 variables researchers have examined in TPB studies related to driving behavior, this study identified the six that are commonly used to enhance the TPB model’s predictive power. These variables are past behavior, self-identity, descriptive norm, anticipated regret, risk perception, and moral norm. When past behavior is added to the original TPB model, it increases the explained variance in intention to 52%. When all six factors are added to the original TPB model, the best model has only four variables (perceived risk, self-identity, descriptive norm, and moral norm); this model increased the explained variance to 48%. The influence of the TPB constructs on intention is modified by behavior category and traffic category. The findings of this paper validate the application of TPB to predict driving behavior. It is the first study to do this through the use of meta-analysis and structural equation modeling

A Passivity-based Control Combined with Sliding Mode Control for a DC-DC Boost Power Converter

In this paper, a passivity-based control combined with sliding mode control for a DC-DC boost power converter is proposed. Moreover, a passivity-based control for a DC-DC boost power converter is also proposed. Using a co-ordinate transformation of state variables and control input, a DC-DC boost power converter is passive. A new plant is zero-state observable and the equilibrium point at origin of this plant is asymptotically stable. Then, a passivity-based control is applied to this plant such that the capacitor voltage is equal to the desired voltage. Additionally, the sliding mode control law is chosen such that the derivative of Lyapunov function is negative semidefinite. Finally, a passivity-based control combined with sliding mode control law is applied to this plant such that the capacitor voltage is equal to the desired voltage. The simulation results of the passivity-based control, the sliding mode control and the passivity-based control combined with sliding mode control demonstrate the effectiveness and show that the capacitor voltage is kept at the desired voltage when the desired voltage, the input voltage E and the load resistor R are changed. The results show that compared with the passivity-based control, the passivity-based control combined with sliding mode control has better performance such as shorter settling time, 8.5 ms when R changes and it has smaller steady-state error, which is indicated by the value of integral absolute error (IAE), 0.0679 when the desired voltage changes. The paper has limitations such as the assumed circuit parameters

Seawater desalination using air gap membrane distillation-an experimental study on membrane scaling and cleaning

The connection between operating temperature and membrane scaling/cleaning during an air gap membrane distillation (AGMD) process of seawater has been systematically elucidated in this study. Experimental and mathematically simulated data demonstrate the profound influences of feed salinity and membrane scaling on water flux at various operating temperatures. Feed salinity exerted significant impacts on water flux at high operating temperatures because of aggravated polarization effects. Membrane scaling and the subsequent membrane cleaning efficiency were also strongly affected by operating temperatures. Indeed, membrane scaling was more severe and occurred at a lower water recovery when operating at 60-50 °C (feed-coolant temperature) compared to that at 35-25 °C. Moreover, membrane cleaning with fresh water and vinegar was less effective for the membrane scaled at 60-50 °C compared to 35-25 °C. Finally, membrane cleaning using vinegar was much more efficient than fresh water. Given the availability of vinegar at household level, vinegar cleaning can potentially be a low cost and readily accessible approach for MD maintenance for small scale seawater desalination applications in remote coastal communities

Information Asymmetry and firm value : Is Vietnam different?

© 2019 Elsevier B.V. Using firm-level data from 250 non-financial companies with 2,500 firm-year observations collecting from two stock exchange markets in Vietnam covering a 10-year period from 2008 to 2017, this paper examines the relationship between information asymmetry and firm value in Vietnamese firms. The findings reveal that fundamentally, information asymmetry in Vietnamese firms has a negative impact on firm value. Although this conclusion is consistent with that in the literature underlying by pecking order and agency cost theories, the value of information asymmetry related variables is higher than that in similar studies conducted in other developed countries. The results also find that the financial leverage in Vietnamese firms is higher than in other developed countries but can only play a limited role in mitigating the negative impact of information asymmetry on firm value. All in all, the findings relating to all variables used in the study highlight that Vietnam is a typical emerging country because there is a precise distance from other developed countries

The Nonlinearity of Working Capital and Cross-Sectional Stock Returns: Does Financial Constraints Matter?

This study is the first to examine the impacts of working capital (WC) and financial constraints on cross-sectional stock returns in Taiwan. The findings indicate a non-linear relationship between WC and stock returns. Moreover, the nonlinearity between WC and cross-sectional stock returns is robust after controlling for financial constraints, risk, and growth factors, before the Covid-19 pandemic. In contrast, there is no evidence of nonlinearity between WC and stock returns throughout the Covid-19 outbreak. In addition, the study shows that any deviations from the minimum WC level enhance the stock returns cross-sectionally. It is found that a positive Deviation effect exists in the Taiwan stock exchange before the Covid-19 pandemic by employing portfolio sorting methodologies. The return difference of the long buying highest Deviation and short selling lowest Deviation portfolios earn from 0.6% to 0.9% per month after controlling for financial constraints, risks, and growth factors. Interestingly, it is determined that the deviation effect becomes negative for small stocks during the Covid-19 pandemic, implying that investors prefer small stocks to maintain minimum working capital. The results support the trade-off theory and liquidity preference theory. Finally, the study provides insights into working capital management for managers, and investment strategies for investors during the pandemic

Engagement report on participation in SUN CSA meetings and related meetings with nutrition platforms in 2022

The CGIAR Initiative on Asian Mega-Deltas’ Work Package 2 (WP2) researchers from the Alliance Bioversity and CIAT engaged with a wide range of stakeholders in relevant nutrition platforms, including The Technical Working Group on Nutrition (TWGN) and Scaling Up Nutrition Civil Society Alliance (SUN CSA). The purpose of the engagement is to explore partnerships promote co-learning, and share information for WP2 on Nutrition-sensitive Agri-food systems. These activities will help mainstream the nutrition-sensitive approach to the current activities of relevant nutrition platforms in Vietnam

National Stakeholder Consultation on Nutrition-Sensitive Agri-Food Systems Policy and Literature Review in Cambodia

The report is about the national stakeholder consultation on nutrition-sensitive agrifood systems policy event co-organized by the International Institute of Rural Reconstruction (IIRR), the Alliance of Bioversity and CIAT (the Alliance), the Council for Agricultural and Rural Development (CARD), and the Scaling Up Nutrition Civil Society Alliance (SUN CSA) in Cambodia on 13 December 2022