Availability, price, and affordability of WHO priority maternal and child health medicine in public health facilities of Dessie, north-East Ethiopia

Maternal and child health (MCH) focuses on the determinants, mechanisms, and systems that promote and maintain the health, safety well-being, and appropriate development of children and their mothers in communities and societies to enhance the future health and welfare of society and subsequent generations [1]. Accessing essential medicines that satisfy the priority health care needs of the population is the backbone of the health care and well-being of individuals and populations [2].

The United Nations Population Fund and World Health Organization (WHO) launched the global list of priority medicines for mothers based on a global burden of disease and the evidence of efficacy and safety for preventing or treating maternal, newborn, and child mortality and morbidity [3].

The estimated global spending on health will increase from 9 to 21 trillion United States dollars in 2014 to 24 to 24 trillion United States dollars in 2040 [4]. However, lack of access to essential medicines for MCH remains a major challenge in many developing countries, where more than half of their populations lack access to essential medicines [5]. This will inevitably constrain efforts to reduce mortality and improve the health of children and mothers [6].

Nearly 4.7 million mothers, newborns, and children die each year in sub-Saharan Africa [7], 1.2 million babies die before they reach one month of age and 3.1 million children who survived their first month of life die before their fifth birthday [8]. The mortality of under-five children was 6.3 million in 2013, around 15, 11, and 7% of them were caused by pneumonia, diarrhea, and malaria, respectively, [9]. Ethiopia is one of the sub-Saharan countries with high rates of maternal and child mortality [10].

Early diagnosis and treatment with simple antibiotics could avert as many as 600,000 deaths in cases of pneumonia, whereas improving access to oral rehydration salt (ORS) would save as many of 1.3 million children die annually from diarrhea [9]. The provision of affordable, high-quality, and appropriate essential medicines is a vital component of a well-functioning health system [11] to counteract any existing barriers that might hinder medicine access [12]. Nearly 10 million lives could be saved by improved access to essential medicine [13].

In Ethiopia, pharmaceutical product availability was found to be weak, which suggests that supply chain factors may adversely affect the outcomes of MCH programs [14]. Accepting and application of MCH care policy as a general does not minimize the mortality rate of vulnerable groups due to the absence of medicines. Although few studies have been conducted, the WHO/HAI survey recommends the methodology to be applied at the state or provincial level.

Ten public health facilities (2 hospitals and 8 health centers) were included in this study. In all health facilities, the responsible person for managing priority medicines was a pharmacy technician and 9 (90%) did not receive training in logistics. Averages mean years working experience store man position and at that, public health facility was 0.96 and 1.6 years, respectively.

Universal health coverage is a comprehensive health system approach that facilitates a wide range of health services and significantly improves the life expectancy of patients [23]. Medicines are an essential component of healthcare delivery in any country. In developing countries, equitable access to safe and affordable medicines is crucial to the health and well-being of people. Despite progress made so far in the areas of public health, medicines remain the single most vital factor in the maintenance of health and the treatment of diseases [24].

In this study, the overall mean period availability of the WHO prioritized MCH medicines in public health facilities in the past 6 months was 34.02%. These findings were similar to the study conducted by Abrha (2018), where the availability of priority life-saving was 34.1% [25]. This is also consistent with a study conducted by Sautenkova N et al. (2012) [26].

According to Gelders S et al. (2006) criteria, [17] the present finding was very low. Lower periodic availability was also reported as compared to a study done by Prinja S et al. (2015) in India, where the overall mean availability of medicines was 45.2 and 51.1% Punjab and Haryana, respectively, [27]. In the Republic of Moldova, the mean availability in the public sector was 51.2% [28] and 46% mean availability was reported in Guatemala by Anson et al. (2012) [29].

The variations in the availability of WHO priority MCH medicines among studies might be due to poor inventory management systems and inadequate allocation of funds to health facilities to purchase sufficient amounts of MCH medicines. Financial constraints or inefficient budget utilization for the treatment of chronic and acute conditions and the absence of dollar currency to purchase vital medicines from outside countries have more worsen problems in medicine availability in the health sector.

The government also does not allocate sufficient funds to mobilize MCH care services and neglect such services to non-governmental organizations to facilitate the program, which creates a question on a mandate for the unavailability of medicines. Although priority lifesaving drugs are used for the treatment of various diseases conditions in children and adults [30], many deaths were due to conditions that could be prevented or treated with access to vital medicines at public health facilities [31]. Health insurance coverage and the package of services covered by health insurance plans were shown to increase the affordability of a vast portion of the medical goods and services that are commonly paid for out-of-pocket expenditure [32].

Medicines such as cefixime 400 mg, betamethasone injection 6 mg/mL, medroxyprogesterone acetate, and artemsinin completely absent in public health facilities. This was similar to the absence of essential medicines in the northern part of Ethiopia [25]. This might be due to the longer time required to update newly emerging WHO priority medicines to treatment guidelines at the country level and letter in the hospital and health center level. The absence of a legal accusation system for the non-availability of WHO priority MCH medicines is also the claimed reason.

In this study, the overall public health facility average mean number of stock-out days was 128.9 over 6 months. A high number of stock-out days as compared to the study conducted by Fentie (2015) in Gondar (30.5 days) [33] and lower than Kibira (2017) study 13 reproductive, maternal, newborn, and child health commodities and stock-outs ranged from 14 days [34]. This difference might be attributed to poor stock management, quantification, and procurement practices.

The mean average number of stock out was 2.29, and once for individual drugs like oxytocin injection and amoxicillin dispersible tablets 250 mg which is lower (9.1) compared to the stock-outs of essential health products in Mozambique and for drugs such as oxytocin, the number of stock out was 2.6 at the district level [35]. This finding also lower than that done by Getahun et al. (2015), where amoxicillin 250 mg scored dispersible tablets number of a stock-out was 33 [36]. This might be due to differences in the study period; they conducted a longer period (almost 3 years). Regular and consistent availability of the necessary medicines is the topmost priority for any health sector. A shortage of pharmaceuticals adversely affects the quality of health care and the condition will be severe if stock out is prolonged.

Inadequate supply from the supplier, lack of information about MCH medicines and expiry were the mentioned reasons for stock out of WHO-prioritized MCH medicines. This reason was similar to the study conducted by Getahun et al. [36]. This might be because the pharmaceutical supply to public health facilities throughout the country is being managed by the same supplier [37] as a result of the lack of a strong information communication system between the supplier.

The mean average point availability in the overall health facility was 33.5%, and on the day of the assessment, stock-outs of medicines were ampicillin 500 mg injection, ceftriaxone 1 g injection, ceftriaxone 500 mg injection sodium chloride injectable solution, methyldopa 250 mg tablet, female condoms, and ringer lactate solution. This finding was lower than that of a study in Malawi reported that the overall mean availability was 60% and stock-outs of at least one product on the day of the assessment [14]. This discrepancy was attributed to the expiry of medicines before use.

In the present study, the lowest-paid government worker in Dessie town unable to purchase the product to cover the full course of treatment like ceftriaxone 1 g injection, hydralazine 20 mg injection, and tetanus antitoxin, which require more than daily wages. The results were lower than studies in China, where the affordability of amoxicillin 250 mg for the treatment of severe pneumonia was 1.4 [38]. A study conducted by van Mourik M revealed that for treatment of infectious disease with ceftriaxone 1 g injection, 15 days wages required [39]. The lowest-paid government worker was unable to afford due to their lower financial income [20]. The rising out-of-pocket health spending continues to threaten the affordability of medical care [40, 41].

The MPR was 4 (55.5%) and was considered to be high. The ORS sachets of 1 l were 3.19 times greater, gentamycin injection was 2.14 times greater, and Amoxicillin 250 mg 0.65 times lower than international median prices. This was a higher MPR (1.53) as compared to the Sado E and Sufa A study [42]. Wang X et al. (2014) study revealed that the MPR for ORS was (2.22) and the MPR for amoxicillin (1.82) [43]. Such differences among studies might be due to price inflation of the dollar exchange rate and profit markup range added to retail patient prices for medicines. Some medicines supplied from donors without a price and this medicine, price setting are used for auditing purposes. Besides, high prices were more pronounced when purchasing done from private wholesales during stock out. Although the cost of health care services for MCH, including WHO prioritize medicines was covered by the government, the burden still relies on the government. Catastrophic household health expenditure from out-of-pocket expenditure on medicines could plunge patients into poverty [44].

The availability and affordability of medicines with reasonable prices in public health facilities have strong clinical implications for reducing maternal, newborn, child morbidity, and mortality. This study has significant for the government, stakeholders, managers, and policymakers to develop national regulations and strategies to enhance access to WHO priority MCH medicines for public health facilities.

The point and period availability formula consider the availability of medicines ranging from low to overstock regardless of health institutions need. Nevertheless, in the real world, the availed WHO prioritize MCH medicines might not be sufficient and do not show how much amount of medicines are adequate. The affordability formula failed to incorporate the wages of people in the informal sector who were below the salary income of the government. Moreover, in the MPR calculation, the international price used for comparison was the list of medicine by management science for the health 2015 version and does not update yet, and it has limitations in revealing the MPR ratio at present time. The WHO/HAI price project recommended collecting the price on targeted medicines at state or provincial the result was specific to the surveyed province and thus cannot be generalized to the country.

The average mean availability of WHO prioritized MCH medicines in the past 6 months and point mean availability was very low and a high number of stock-outs. One-third of WHO prioritized medicines were completely unmanaged in all health facilities. From the WHO priority list of medicines, some of the products were unaffordable. Improving availability and strict inventory control are recommended to have a steady supply of these essential medicines to improve the quality of health services.