Medicines Coverage and Community-Based Health Insurance in Low-Income Countries

Objectives: The 2004 International Conference on Improving Use of Medicines recommended that emerging and expanding health insurances in low-income countries focus on improving access to and use of medicines. In recent years, Community-based Health Insurance (CHI) schemes have multiplied, with mounting evidence of their positive effects on financial protection and resource mobilization for healthcare in poor settings. Using literature review and qualitative interviews, this paper investigates whether and how CHI expands access to medicines in low-income countries. Methods: We used three complementary data collection approaches: (1) analysis of WHO National Health Accounts (NHA) and available results from the World Health Survey (WHS); (2) review of peer-reviewed articles published since 2002 and documents posted online by national insurance programs and international organizations; (3) structured interviews of CHI managers about key issues related to medicines benefit packages in Lao PDR and Rwanda. Results: In low-income countries, only two percent of WHS respondents with voluntary insurance belong to the lowest income quintile, suggesting very low CHI penetration among the poor. Yet according to the WHS, medicines are the largest reported component of out-of-pocket payments for healthcare in these countries (median 41.7%) and this proportion is inversely associated with income quintile. Publications have mentioned over a thousand CHI schemes in 19 low-income countries, usually without in-depth description of the type, extent, or adequacy of medicines coverage. Evidence from the literature is scarce about how coverage affects medicines utilization or how schemes use cost-containment tools like co-payments and formularies. On the other hand, interviews found that medicines may represent up to 80% of CHI expenditures. Conclusion: This paper highlights the paucity of evidence about medicines coverage in CHI. Given the policy commitment to expand CHI in several countries (e.g. Rwanda, Lao PDR) and the potential of CHI to improve medicines access and use, systematic research is needed on medicine benefits and their performance, including the impacts of CHI on access to, affordability, and use of medicines at the household level

Prescribing for acute childhood infections in developing and transitional countries, 1990–2009

Background: Evidence of global progress in treating acute paediatric infections is lacking. Objectives: To assess progress over two decades in prescribing for childhood infections and interventions to improve treatment by reviewing empirical evidence in developing and transitional countries. Methods: Data were systematically extracted on the use of medicines for diarrhoea, respiratory infections and malaria from published and unpublished studies (1990–2009) in children under 5 years of age. Medians of each indicator were calculated across studies by study year, geographic region, sector, country income level and prescriber type. To estimate intervention effects from studies meeting methodologically accepted design criteria [randomised controlled trials (RCTs), pre-post with control, and time series studies], the medians of the median effect sizes (median MES) were calculated across outcome measures. Results: Data were extracted from 344 studies conducted in 78 countries with 394 distinct study groups in public (64%), private (22%) and other facilities to estimate trends over time. Of 226 intervention studies, only the 44 (19%) with an adequate study design were used to estimate intervention effects. Over time, use of anti-diarrhoeals for acute diarrhoea decreased significantly (P<0·01). However, treatment of malaria and acute respiratory infection remained largely sub-optimal. Multi-component interventions resulted in larger improvements than single-component ones. The median MES indicated a 28% improvement with community case-management, an 18% improvement with provider education combined with consumer education, but only 9% improvement with provider education alone. Conclusions: While diarrhoea treatment has improved over the last 20 years, treatment of other childhood illnesses remains sub-optimal. Multi-component interventions demonstrated some success in improving management of acute childhood illness

Comparative assessment of medicine procurement prices in the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)

Objectives: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the main primary healthcare provider for 4.9 million Palestinian refugees, spent USD18.3 million on essential medicines dispensed free-of-charge through clinics in five areas of operation (‘fields’): Gaza, Jordan, Lebanon, Syria, and the West Bank (2010). Faced with budget contraints and an increasing demand for medicines to treat chronic conditions, the objective of our study was to assess UNRWA’s medicine procurement prices to see if savings could be possible. Methods: In July 2011, data was collected from UNRWA headquarters in Jordan. Price analyses focused on the top 80 medicines by value, accounting for 93% of pharmaceutical expenditure from the General Fund, with comparisons to international, regional and national references. Prices were also compared for the few medicines procured both through UNRWA’s central tender (centrally) and by the fields directly (locally). Results: Central procurement prices did not differ markedly from reference prices: median ratios of UNRWA prices to Management Sciences for Health’s International Drug Price Indicator Guide, Jordan’s Joint Procurement Department, Gulf Cooperation Council, and IDA Foundation bulk packs were 0.99, 1.00, 0.98 and 1.12 respectively. Applying the lowest comparator price to five comparatively higher priced medicines would yield savings of USD1.4 million. Local procurements were generally less cost-effective than central tender procurement, with notable differences across fields and medicines. Conclusions: Overall, UNRWA’s procurement prices were competitive despite the relatively small quantities procured. Regular monitoring of procurement prices and quantities is needed in order to make informed decisions. Our evaluation also underscores the heavy burden of antidiabetic medicines and antimicrobials on UNRWA procurement expenditure

First regulatory inspections measuring adherence to Good Pharmacy Practices in the public sector in Uganda: a cross-sectional comparison of performance between supervised and unsupervised facilities

GPP inspection indicators with classification (critical, major, and minor) and overlap with SPARS indicators indicated with*, partly overlap **. (DOCX 145 kb

Have we improved use of medicines in developing and transitional countries and do we know how to? Two decades of evidence

Objective: To assess progress in improving use of medicines in developing and transitional countries by reviewing empirical evidence, 1990–2009, concerning patterns of primary care medicine use and intervention effects. methods We extracted data on medicines use, study setting, methodology and interventions from published and unpublished studies on primary care medicine use. We calculated the medians of six medicines use indicators by study year, country income level, geographic region, facility ownership and prescriber type. To estimate intervention impacts, we calculated greatest positive (GES) and median effect sizes (MES) from studies meeting accepted design criteria. results Our review comprises 900 studies conducted in 104 countries, reporting data on 1033 study groups from public (62%), and private (mostly for profit) facilities (26%), and households. The proportion of treatment according to standard treatment guidelines was 40% in public and <30% in private-for-profit sector facilities. Most indicators showed suboptimal use and little progress over time: Average number of medicines prescribed per patient increased from 2.1 to 2.8 and the percentage of patients receiving antibiotics from 45% to 54%. Of 405 (39%) studies reporting on interventions, 110 (27%) used adequate study design and were further analysed. Multicomponent interventions had larger effects than single component ones. Median GES was 40% for provider and consumer education with supervision, 17% for provider education alone and 8% for distribution of printed education materials alone. Median MES showed more modest improvements. conclusions Inappropriate medicine use remains a serious global problem

Active pharmaceutical management strategies of health insurance systems to improve cost-effective use of medicines in low- and middle-income countries: A systematic review of current evidence

Objectives Health insurance systems have great potential to improve the cost-effective use of medicines by leveraging better provider prescribing, more cost-effective use by consumers, and lower prices from industry. Despite ample evidence from high-income countries, little is known about insurance system strategies targeting medicines in low- and middle-income countries (LMIC). This paper provides a critical review of the literature on these strategies and their impacts in LMIC.Methods We conducted a systematic review of published peer-reviewed and grey literature and organized the insurance system strategies into four categories: medicines selection, purchasing, contracting and utilization management.Results In n = 63 reviewed publications we found reasonable evidence supporting the use of insurance as an overall strategy to improve access to pharmaceuticals and outcomes in LMIC. Beyond this, most of the literature focused on provider contracting strategies to influence prescribing. There was very little evidence on medicines selection, purchasing, or utilization management strategies.Conclusions There is a paucity of published evidence on the impact of insurance system strategies on improving the use of medicines in LMIC. The existing evidence is questionable since the majority of the published studies utilize weak study designs. This review highlights the need for well-designed studies to build an evidence base on the impact of medicines management strategies deployed by LMIC insurance programs.Essential medicines Drug utilization Health insurance Health policy Cost effectiveness

Medicines coverage and community-based health insurance in low-income countries

Abstract Objectives The 2004 International Conference on Improving Use of Medicines recommended that emerging and expanding health insurances in low-income countries focus on improving access to and use of medicines. In recent years, Community-based Health Insurance (CHI) schemes have multiplied, with mounting evidence of their positive effects on financial protection and resource mobilization for healthcare in poor settings. Using literature review and qualitative interviews, this paper investigates whether and how CHI expands access to medicines in low-income countries. Methods We used three complementary data collection approaches: (1) analysis of WHO National Health Accounts (NHA) and available results from the World Health Survey (WHS); (2) review of peer-reviewed articles published since 2002 and documents posted online by national insurance programs and international organizations; (3) structured interviews of CHI managers about key issues related to medicines benefit packages in Lao PDR and Rwanda. Results In low-income countries, only two percent of WHS respondents with voluntary insurance belong to the lowest income quintile, suggesting very low CHI penetration among the poor. Yet according to the WHS, medicines are the largest reported component of out-of-pocket payments for healthcare in these countries (median 41.7%) and this proportion is inversely associated with income quintile. Publications have mentioned over a thousand CHI schemes in 19 low-income countries, usually without in-depth description of the type, extent, or adequacy of medicines coverage. Evidence from the literature is scarce about how coverage affects medicines utilization or how schemes use cost-containment tools like co-payments and formularies. On the other hand, interviews found that medicines may represent up to 80% of CHI expenditures. Conclusion This paper highlights the paucity of evidence about medicines coverage in CHI. Given the policy commitment to expand CHI in several countries (e.g. Rwanda, Lao PDR) and the potential of CHI to improve medicines access and use, systematic research is needed on medicine benefits and their performance, including the impacts of CHI on access to, affordability, and use of medicines at the household level.</p

Treatment of Febrile illness with artemisinin combination therapy: prevalence and predictors in five African household surveys

Objectives: To evaluate the determinants of compliance with national policies recommending Artemisinin Combination Therapy (ACT) for the treatment of uncomplicated malaria in the community. Methods: We used data from Gambia, Ghana, Kenya, Nigeria, and Uganda national household surveys that were conducted with a standardized World Health Organization (WHO) methodology to measure access to and use of medicines. We analyzed all episodes of acute fever reported in the five surveys. We used logistic regression models accounting for the clustered design of the surveys to identify determinants of seeking care in public healthcare facilities, of being treated with antimalarials, and of receiving ACT. Results: Overall, 92% of individuals with a febrile episode sought care outside the home, 96% received medicines, 67% were treated with antimalarials, and 16% received ACT. The choice of provider was influenced by perceptions about medicines availability and affordability. In addition, seeking care in a public healthcare facility was the single most important predictor of treatment with ACT [odds ratio (OR): 4.64, 95% confidence intervals (CI): 2.98–7.22, P < 0.001]. Children under 5 years old were more likely than adults to be treated with antimalarials [OR: 1.28, CI: 0.91–1.79, not significant (NS)] but less likely to receive ACT (OR: 0.80, CI: 0.57–1.13, NS). Conclusions: Our results confirm the high prevalence of presumptive antimalarial treatment for acute fever, especially in public healthcare facilities where poor people seek care. They show that perceptions about access to medicines shape behaviors by directing patients and caregivers to sources of care where they believe medicines are accessible. The success of national policies recommending ACT for the treatment of uncomplicated malaria depends not only on restricting ACT to confirmed malaria cases, but also on ensuring that ACT is available and affordable for those who need it