Availability and affordability of children essential medicines in health facilities of southern nations, nationalities, and people region, Ethiopia: key determinants for access

A high standard of health is a basic right for every human [1]. Individuals and societies have the responsibility to ensure that this basic human right is achieved. Access to essential medicines (EMs) is a necessary tool for ensuring the health of individuals and communities. EMs have been identified in prior research based on community health relevance, evidence on efficacy, safety, and comparative cost-effectiveness [2]. EMs are expected to be available from health systems at all times in adequate amounts, in the proper dosage forms, with assured quality and sufficient information, and at a price, the individual and the society can afford [3].

However, access to EMs is challenging; especially for children. Some of the factors which impaired children’s access to EMs were lack of suitable dosage forms, the high price of medicines, inefficient government procurement culture, extreme mark-ups in the distribution chain, and exaggerated taxes and duties being applied to these medicines [4‐7]. Even though its necessity was emphasized in Millennium Development Goals/MDG/ four and six, Sustainable Development Goals (SDG) goal 3 and WHO launched the ‘Make Medicines Child Size’ campaign to enhance the availability of safe, effective, and quality medicines for children by promoting awareness and action through research, regulatory measures, and changes in policy, effective results for it has not yet been achieved [6, 8‐10].

Thus, millions of children die every day before they reach their fifth birthday, of conditions that could be treatable with existing EMs globally. Of newborn deaths, 22% are due to infections such as pneumonia, diarrhea, and malaria. Childhood pneumonia and diarrhea are the most important causes of childhood mortality and account for about 30% of all child deaths worldwide [11, 12]. The majority of these children would endure if they have given appropriate available EMs [13]. For instance, oral antibiotics administered in community settings can reduce all sources of neonatal mortality by 25% and pneumonia-related mortality by 42%; zinc administration for diarrhea management can reduce all-cause mortality by 46% [14, 15]. The scenario worsens in resource-constrained nations. Children in developing countries are more liable to die from treatable conditions than those in higher resource settings due to a lack of access to the correct medication at the right time [16].

Access to EMs can be determined by availability, affordability, accessibility, acceptability, accommodation/adequacy, and/or quality of the medicines [17, 18]. However, programs such as ‘Better Children’s Medicines’ stressed that improving access to children’s EMs is more applicable by addressing issues of accessibility, safety, efficacy and price (affordability) [19]. As per the studies, assuring availability and affordability of medicines play a vital role in improving children’s access to EMs in both private and public sectors. Availability is reported as the percentage of medicine outlets in which medicine was found on the day of data collection and affordability, in other words, is estimated by comparing medicine costs to the daily wage of the lowest-paid unskilled government worker (LPGW) [6, 7].

A series of initiatives have been taken by Ethiopia to improve access to EMs. A three-tier health-delivery service system was introduced to address accessibility issue. The primary level consisting of health posts (HPs), health centers and primary hospitals are made accessible to the majority of population to provide promotion, preventive and curative services; general hospitals provide secondary level services; and specialized hospitals provide tertiary services [20]. Except HPs all public sectors have pharmacies. Regarding private sector, the pharmaceutical retail system also has three outlets levels: pharmacy (run by pharmacist), drug store (run by druggist) and rural drug vendor. Except rural drug vendor the rest can stock and dispense EMs found in the national essential drug list (NEDL) [21]. As less bureaucracy is needed and more attractive services are given, they are preferred sources of EMs.

To eliminate an interrupted drug supply, drug price variation and promote the availability, pharmaceuticals fund and supply agency (PFSA) under Proclamation No. 553/2007 based on the pharmaceuticals logistics master plan (PLMP) was established [22]. Besides, for some diseases, a relaxed program called program drugs is there to consider EMs from donors and NGOs dispense them freely [23]. Finally, to counter financial hindrance (where patients fully pay out-of pocket money for the services they get) and advance affordability, community-based health insurance (CBHI) was launched and being scaled up [24]. Further, a waiver system installed grants the poorest access to free health care and free medicines [25].

Despite these initiatives, the country is still confronted with low access to children’s EMs. In a study conducted in South-west Ethiopia, 55.65% of EMs were available, and considerable price variation among studied sectors impeded access to EMs [26]. In Western Ethiopia, the average availability of EMs for children was found to be 43%. Again the price of EMs was making treatment unaffordable, and low public awareness to participate in CBHI and the government’s weak campaign could not spare the community from paying out-of-pocket money for budget EMs [27]. This study, therefore, sought to assess the availability and affordability of CEMs based on WHO/HAI methodology to determine children’s access to EMs in Southern Ethiopia to have a semi-complete picture of the problem together with already published work [27, 28].

The current study utilized Chahal, H.S. et al, work to present the cut-off for the EMs availability percent range. Accordingly, 6 and 12 EMs were highly available (> 80%) in the public and private sectors respectively [31]. Private sectors were good at having highly available EMs compared to their encounters. This may be due to their flexible reordering time, and refilling their consumption before stock-out looking at demand trends. Public-sectors are abide by law when and form whom to reorder—they are not permitted to procure simply because of EMs are below certain level. They have to follow stirict rules and wait until their reorder time. Such low availability of overused EMs are usually occurs as a result of poor consumption forecasting and procurement. Since stock-movement in both sectors is not similar, only 5 of these highly available EMs were found. The supply of highly consumable EMs in the public sector will decline as it reachs the store of the HFs before the day of reorder, while refilling is immidiate in private sectors as there is fast stock movemnt. On the other hand, for 3 EMs in the public sector and 6 EMs in the private sector, low availability (< 30%) was reported, with 3 EMs being < 30% in both. Eighteen and 7 EMs in the public and private sectors respectively kept a broader range (30–80%) of availability.

The average availability of LP medicines for children was fairly high in both sectors [31]. It was 57.67% in public sectors and 53.67% in private sectors. However, none of the selected districts’ HFs stocked beclomethasone inhaler, morphine 10 mg/5 ml oral solution, and carbamazepine 100 mg/5 ml suspensions. Regarding the higher availability of medicines in the public sector compared to the private sector, these findings are consistent with the results of a study done by Edao Sado and Alemu Sufa, in the Western part of Ethiopia, for a similar target [27]. Studies like the compiled reports of WHO and Anson A et al results disagree with the current work by finding low average availability of medicines in the public than private sectors [7, 33]^.

PFSA, the country’s largest source of medicine, is now turning its office work into the field [38]. It helps the clients to engage from medicine selection to rational use. It is trying to have the actual needs of each health institution found in the country. This shift could allow health institutions to increase the availability of EMs.

The average availability of medicines used to treat chronic conditions such as seizure disorders and asthma in children was low (≈42%) [31]. As carbamazepine and beclomethasone (alternative EMs) were totally absent, there was no mitigation for the observed low availability. This is attributed to parents’ inadequate knowledge of diseases and the weak capacity of health facilities to diagnose and manage cases [9]. Appropriate demand definition reports should therefore not be correctly established to acquire adequate supply.

Medicines offered free of charge from the public sectors like artesunate 60 mg and vitamin A were found below 50%. This is because malaria is a seasonal epidemic. Its drug stock usually varies. Only when the need arises, drugs such as artesunate and coartem are procured and refilled free of charge from the source (Regional Health Bureau). Otherwise, the inventory resides in the central store. Regarding vitamin A, the service is mainly provided by health posts and they were also not part of this research. Private sectors do not have much interest in stock because these drugs are dispensed free of charge and their demand is low. When they disregard isoniazid stocking, such lack of interest was assured. In addition, the prescriber’s desire for other alternatives, the negative thinking relating to opioid abuse, and being categorized under the Narcotic and Psychotropic Substance (NPS), caused morphine not to be stocked.

Infectious diseases are known causes of childhood morbidity and mortality [11, 12, 16]. The availability of medicine used to tackle these conditions has to be maintained at the optimum level (≥ 50%). However, the average availability of chloramphenicol 1 g was below the ‘very low’ level [31]. Presence of safe alternative medicines and unwanted effects of chloramphenicol in children caused a decline in demand and supply. Procaine penicillin could not be held in the majority of studied drug sources due to the update of the treatment protocol. The dispersible tablet of augmentin (amoxicillin 125 mg + clavulinic acid 31.25 mg) was found in 2 public and 2 private sectors. As children prefer the form of suspension dosage to the tablet, and due to the price issue it was hardly available. Amoxicillin 250 mg dispersible tablet as a result of low interest/low priority by consumers and benzyl penicillin due to lesser/no stock movement, private sectors showed less willingness to include them in their retails.

Irrational antibiotic use, on the other hand, may decrease the availability of EMs during the study period in the study area. Since they are prescribed for diseases unconfirmed by laboratory diagnosis, such as for viral origin, or prescribed if not required, or the poor controlling system that could not give up obtaining them without a prescription for self-medication could affect the stock [39].

The current study also showed that the overall retail prices of the LP medicines were higher than their IRPs. They were sold at 1.26 times their IRPs in the public sectors and 2.24 times their IRPs in the private sectors. Concerning substantially higher prices in private sectors compared to public sectors, this finding is similar to the studies done by Edao Sado and Alemu Sufa, and Sun X et al [27, 40]. A noticeable price variability between both sectors was common for captured medicine in this study. It is consistent with a study undertaken on the availability, prices, and affordability of essential medicines in Ethiopia, Haiti, and china [27, 31, 40]. Such higher than IRPs prices observed in the studied EMs were attributed to (i) the fact that it is appropriate for the public sector to add up to 40% of procurement cost to the price of each EM, while (ii) the private sector having unsolved issues with PFSA, pointing to its costly sources and merely looking at the demand trend (and/or stock-out pattern at public sector), it may unreasonably add exaggerated sums of money for procurement costs to the price. As well as protection, quality, and effectiveness, the medication price control issue emphasized under the National Drug Policy has not been enforced for several reasons [41]. For certain opportunists, such gaps are expedient environments. For example, paracetamol 125 mg suppository was the cheapest EM in the public sector, but in the private sector, it was the most costly EM. The country is promoting local medicine production instead of price regulation and enforcing licensed medicine stocking and dispensing institutions to contract with PFSA.

Managing commonly prevalent conditions—acute and chronic— with standard treatment protocol using the LP medicines in the region was unaffordable (81.82% in public and 91.91% in private) as they cost a day’s or above wage for the LPGW. This finding agrees with the findings of Edao Sado and Alemu Sufa, and Sun X et al [27, 40]. The assumption of the LPGW method for determining the affordability of EMs is that all wages go towards the purchase of medication. For households with an average of 4.6 children, it is not obvious to spend a day’s wage buying medication alone [42]. Low-income earners are likely to spend 93 and 60% of their income on food, housing, transport, utilities, and sport or leisure activities as per Mokaya J et al. and Xu K et al. findings respectively [43, 44]. Accordingly, for healthcare expenses just 7 and 40% of income are left. In the current work, the LPGW requires 0.4 to 2.3 days’ wage (1.33–7.67% income) to afford the cheapest LP medication ORS in the public sector. This would be all right for Mokaya J et al [43]. For an expensive standard treatment of acute otitis media with Augmentin 156.25 mg/5 ml in the private sector, the high income (40%) left is not enough to accommodate as it needed the LPGW’s 19.4 to 110.8 days’ wage (64.67–369.33% income). Thus, almost all the 11 standard treatment options identified in this work were unaffordable. This showed that the government’s target of achieving universal health coverage for its citizens through CBHI and the donor partnership does not seem to improve access because affordability remains an unresolved problem. Not only does the way CBHI exercise impact the accessibility of EMs or the affordability of care, it also deteriorates the entire operation of health institutions, as CBHI financing is handled by those who are least concerned with health and unable to produce the bill on time for the purchase/refill of supplies. Since most people earn less than the specified income at the LPGW, they have either forgo treatment, tried other local healing activities, suspend their basic needs or borrowed.

This study did not assess factors affecting or related to availability, price, and affordability.

The average availability of EMs for children in this work was fairly good. Public sectors have relatively higher availability than private sectors provided that government-subsidized, free of charge offered and public sectors only allowed to stock medicines were included in the study. However, the average LP MPR for public and private sectors being 1.57 and 2.54 times their IRPs compromises children’s access to EMs respectively. Furthermore, being unaffordability of LP medicines for 81.82 and 90.91% of full-course standard treatments of prevalent conditions in the public and private sectors as they cost a day’s or above wages for the LPGW respectively, lowering childhood morbidity and mortality questionable.