Understanding the dynamics of accessing chronic medicines in the public sector: Implications for policy in South Africa

Philosophiae Doctor - PhD (School of Public Health)Access to medicines (ATM), specifically for those medicines that are related to the priority health needs of a population has been cited as a fundamental part of universal health coverage and a key element for service delivery and high-quality care. Therefore, ensuring reliable access to and appropriate use of safe, effective and affordable medicines is one of the core functions of an effective health system. With the rising demand for treatment of chronic diseases (e.g. HIV, diabetes and hypertension), ATM has increasingly received global attention. Yet as of 2011, it was estimated that at least one third of the world's population had no regular access to medicines. Globally, there is a dearth of in-depth country level evidence to influence policy responses, coupled with inadequate understanding of how pharmaceutical systems operate within broader health systems. This thesis comprises two main parts: 1) a situational analysis of the state of chronic medicines provision in the public sector in the Eastern Cape and Western Cape provinces of South Africa; and (2) an evaluation of an existing ATM model in one province. To situate this study within the ATM discourse, a conceptual framework was developed from a review of empirical and theoretical literature. The framework incorporated six ATM dimensions (availability, affordability, acceptability, accessibility, accommodation and quality) and their interplay at multiple levels including: health facility, individual, household and community levels. Then, at a health system level, the interaction of medicines (a health system building block) with other building blocks (information, financing, human resources, infrastructure and governance)

Reducing missed opportunities for vaccination in selected provinces of Mozambique: A study protocol [version 1; referees: 2 approved]

Background: A missed opportunity for vaccination (MOV) refers to any contact with health services by an individual who is eligible for vaccination, which does not result in the person receiving the vaccine doses for which he or she is eligible. A consortium of partners, including VillageReach, the Ministry of Health in Mozambique and the World Health Organization, will implement a strategy to reduce MOV in Mozambique. The strategy involves demonstrating the magnitude of missed opportunities and their causes, and exploring tailored health system interventions to reduce them, with the aim of increasing vaccination coverage and timeliness of vaccinations. Methods: A mixed-methods approach will incorporate both quantitative and qualitative tools. The assessment will target caregivers of children between the ages of 0–23 months who attend a health facility in the selected districts on the day of the assessment. Caregivers who are at least 18 years old will be eligible for inclusion. Another component of the assessment will target all health workers in the selected health facilities on the day of the assessment. A sample of 30 health facilities in different regions of the country will be assessed, with a target sample size of 600 caregiver exit interviews, 300 health worker interviews and focus group discussions with both caregivers and health workers. Data collection will commence late 2017, and the data will be electronically captured, managed and analyzed. Thematic analysis of data from the qualitative aspects of the assessment will be conducted, presenting the scope of interviews, representative verbatim quotes and key conclusions.  Conclusions: A concerted effort to reduce or eliminate MOV could increase vaccine coverage by up to 30% and may contribute to wider improvements in efficiencies of service delivery beyond the immunization program. In addition, the findings could contribute to a better understanding of MOV in similar settings

Inefficient procurement processes undermine access to medicines in the Western Cape Province of South Africa

BACKGROUND. South Africa (SA) has experienced several stock-outs of life-saving medicines for the treatment of major chronic infectious and non-communicable diseases in the public sector. OBJECTIVE. To identify the causes of stock-outs and to illustrate how they undermine access to medicines (ATM) in the Western Cape Province, SA. METHODS. This qualitative study was conducted with a sample of over 70 key informants (frontline health workers, sub-structure and provincial health service managers). We employed the critical incident technique to identify significant occurrences in our context, the consequences of which impacted on access to medicines during a defined period. Stock-outs were identified as one such incident, and we explored when, where and why they occurred, in order to inform policy and practice. RESULTS. Medicines procurement is a centralised function in SA. Health service managers unanimously agreed that stock-outs resulted from the following inefficiencies at the central level: (i) delays in awarding of pharmaceutical tenders; (ii) absence of contracts for certain medicines appearing on provincial code lists; and (iii) suppliers’ inability to satisfy contractual agreements. The recurrence of stock-outs had implications at multiple levels: (i) health facility operations; (ii) the Chronic Dispensing Unit (CDU), which prepacks medicines for over 300 000 public sector patients; and (iii) community-based medicines distribution systems, which deliver the CDU’s prepacked medicines to non-health facilities nearer to patient homes. For instance, stock-outs resulted in omission of certain medicines from CDU parcels that were delivered to health facilities. This increased workload and caused frustration for frontline health workers who were expected to dispense omitted medicines manually. According to frontline health workers, this translated into longer waiting times for patients and associated dissatisfaction. In some instances, patients were asked to return for undispensed medication at a later date, which could potentially affect adherence to treatment and therapeutic outcomes. Stock-outs therefore undermined the intended benefits of ATM strategies. Conclusion. Addressing the procurement challenges, most notably timeous tender awards and supplier performance management, is critical for successful implementation of ATM strategies.IS

Behavioural research examining contraceptive practices and fertility intentions of women living with HIV

Thesis (MPhil)--University of Stellenbosch, 2010.ENGLISH ABSTRACT: This study examines whether an HIV positive status will influence fertility decision-making and contraceptive practices of women in living with HIV (WLHIV) or if improved antiretroviral therapy (ART) and regular HIV care can also make a contribution to their choices. The study was qualitative and it utilized a document analysis, a focus group discussion and interviews held in Khayelitsha, South Africa. A total of 30 women living with HIV aged between 18-45 years formed part of the study. Additional interviews were conducted with the health care worker and the Support Group Coordinator. Data was analysed through the identification of emerging themes and grouping of similar data. The responses given by the participants provided an understanding of the thought processes around contraceptive use and fertility decision-making for WLHIV. Evidently, contraceptive practices and fertility intention change over time (due to knowledge change of plans, partner or family opposition, side effects, or changes to their economic or educational situation among other reasons). Although the study population (n=30) was too small to make definite conclusions, the findings seem to tell of a transition towards the realisation of the rights of WLHIV. In spite of the many challenges that are faced by WLHIV, there seems to be a fairly conducive environment (both in terms of policy and resources) to enable WLHIV to fulfil their fertility intentions. However, there is need for programme planners to enhance ways of putting policy into practice. Finally, it would be useful to invest further into research to obtain a broader list of WLHIV’s experiences, their rationale for making certain decisions regarding their reproductive health choices and the level of importance assigned to each reason. This was beyond the scope of this study.AFRIKAANSE OPSOMMING: Hierdie studie ondersoek of 'n HIV positiewe status vrugbaarheidsbesluitneming en voorbehoedpraktyke van vroue wat met HIV leef sal beïnvloed en of verbeterde antiretrovirale terapie (ART) en gereelde HIV sorg ook 'n bydrae sal maak tot hul keuses. Die studie was kwalitatief en dit het gebruik gemaak van dokumentanalise, 'n fokusgroepbespreking en onderhoude wat in Khayelitsha, Suid-Afrika, gevoer is. In totaal het 30 vroue wat met HIV leef (WLHIV), tussen die ouderdomme van 18-45 jaar deel uitgemaak van die studie. Bykomende onderhoude is met gesondheidsorgwerkers en die Koördineerder van 'n ondersteuningsgroep gevoer. Data is geanaliseer deur middel van die identifikasie van temas wat na vore gekom het en die groepering van soortgelyke data. Die deelnemers se antwoorde verskaf 'n begrip van die denkprosesse rondom die gebruik van voorbehoeding en die vrugbaarheidsbesluitneming van WLHIV. Dit blyk dat voorbehoedpraktyke en vrugbaarheidsbegeertes verander met verloop van tyd (weens, onder meer, kennis verandering van planne, opposisie van 'n lewensmaat of familie, newe effekte of verandering aan hul ekonomiese of opvoedkundige situasie). Alhoewel die studie populasie (n=30) te klein was om definitiewe gevolgtrekkings te maak, blyk dit dat die bevindinge dui op 'n transisie in die realisering van die regte van WLHIV. Ten spyte van die vele uitdagings wat WLHIV in die gesig staar, blyk dit dat daar 'n redelik gunstige omgewing (in terme van beide beleid en hulpbronne) is om WLHIV in staat te stel om hul vrugbaarheidsbegeertes te vervul. Tog is dit nodig dat programbeplanners die manier waarop beleide in praktyk omgesit word, verbeter. Uiteindelik sal dit handig wees om verder in navorsing te belê om 'n wyer lys van WLHIV se ondervindings te kry, sowel as hul redes vir sekere besluite rakende hul voorplantingsgesondheid en die vlak van belangrikheid wat aan elke rede geheg word. Hierdie is buite die bestek van hierdie studie