Understanding the dynamics of accessing chronic medicines in rural and urban settings in South Africa

1.1 Overview of health care in South Africa South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of HIV and TB, maternal and child health, non-communicable diseases and violence, injuries and trauma. (Mayosi. et.al, 2009). Ensuring reliable access to, and appropriate use of, safe, effective, and affordable medicines is one of the core functions of an effective health system. (Roberts, M. and Reich, M., 2011) and has become a part of the fulfilment of the fundamental right to health. Chronic diseases pose long-term demands on South Africa‟s already burdened health care system. Few health systems in poorly resourced settings are organized to meet the needs of chronic patients (Goudge et. al., 2009) and they are already burdened with the management of diseases with complex and adverse impacts on health systems (Kotwani, 2010). Improving access to medicines and retention in care is a complex challenge for all actors in the public and private sectors involved in the field of medicines supply and calls for a different focus and approach to Public Health policy and action (Igumbor, 2010) and re-orientation of service delivery in light of the challenges in the health system (Schneider, H. et.al, 2006). Eighty-three percent of the South African population is not covered by medical aid or health insurance (Blecher et.al, 2011) and Primary Health Care (PHC) remains the only effective way of delivering some form of health care. The public sector in South Africa faces increased pressure on the health care system to meet the health needs of the population and health facilities are faced with a high workload and limited human resources to meet the demand for services (Reagon & Igumbor, 2010). This has led to stress and burn out among health care workers, some of whom are also battling with disease themselves. (Benatar, 2004). South Africa has therefore re-affirmed its commitment to primary health care through the Primary Health Care Re-engineering strategy which seeks to strengthen district health systems and ultimately improve health outcomes (Pillay & Barron, 2011). 1.2 Problem Statement Access to medicines is a key feature of a functional health system and there have been recent efforts to recognize medicines not just as a commodity but a key pillar of the health system (WHO, 2009). Patients‟ inability to access medicines remains a key concern for policy makers and threatens clinical outcomes in the event of interrupted treatment cycles. One of the critical needs for strengthening access to medicines is for operational research to inform policy and programmes. Operational research is underused in global health yet its methods are useful for the systematic identification of problems and the search for potential solutions (Royston G, 2011). In South Africa, there have been numerous media reports of stock outs for essential medicines over the past year yet little research has been done to identify and characterise the challenges in the area of drug supply management (Tayob, 2013). For example, the Western Cape Department of Health (WCDOH) is estimated to consume approximately R0, 3 billion per annum on research, but relatively little of that funding speaks to solving the operational and systems challenges facing health services in the province. In a recent report, the department reported that patient experiences of health services are largely negative but the authorities are unaware as to how to use this feedback to constructively in provincial planning processes and contributes to shaping policies and practice in the service areas (WCDOH, 2012). Research has shown that negative experiences with the health system can discourage patients from accessing services (Reagon and Igumbor, 2010). As well as providing ongoing formative feedback to improve access to medicines, a more abstract, interpretive analysis which explores the context-mechanism-outcome relationship for interventions using the guiding question “what works, for whom, under what circumstances?” needs to be utilised (Greenhalgh et.al, 2009; Pawson and Tilley, 2004) in order to inform future policies and planning but also to assess adaptability of specific interventions to other contexts. The delimitations of this study are set on the lower levels of the supply chain, specifically distribution and use where significant variations occur in different contexts and not regulation, selection and procurement functions which are centrally performed by the state. 1.3 Relevance of the Study A recent publication by the Department of Health under the National Health Care Facilities Audit reported a 54% failure in compliance to the vital measure dealing with availability of medicines and recommended priority attention to supply chain management. (HST, 2012). There has also been a spate of media reports on stock-outs of essential medicines at the primary care level in recent years and confidence in the public sector has waned. The South African health system is undergoing a major transition towards a National Health Insurance (NHI) funding system and an overhaul of primary health care through the current reengineering process is key to its success. This presents an opportune time to assess the current downstream barriers to accessing medicines against proposed plans for the NHI and the re-engineering process for improving the distribution and use of medicines. The second sub-study is an assessment of a multi-million dollar public-private partnership between the WCDOH and a private distributor commissioned to package and deliver chronic medicine parcels to stable public sector patients in the Western Cape. This is the only intervention of its kind in the country with express aims to address facility staff shortages and high workloads by depopulating primary healthcare facilities, reducing waiting times and improve patient adherence (see Annex 1 for more detail). The intervention, now in its eighth year has not been evaluated and policy makers are keen to know what is working well, what is not and how can processes be improved. For instance, over the last few months there has been an increased rate of non-collected parcels which are returned to the Cape Town CDU depot; however the reasons and the magnitude of this problem are unknown. Some of the questions that arise which this research will elucidate are whether CDU objectives are appropriately aligned with demand needs e.g. why are patients not meeting their appointments?; What are the consequences for facility e.g. in terms of storing uncollected parcels; and what are the consequences to the CDU in terms of costs? In May 2013, the Department of Health issued a moratorium to stop facilities from returning non-collected parcels as this was a costly exercise. Finally, the research will ascertain whether central dispensing an answer to supply chain challenges can be adapted in other settings.

Trefwoorden:B680-volksgezondheid

Project type:PhD project