When the World Health Organisation created an essential medicines list in the early 2000s, the aim was to provide a list of medicines that should be made available and accessible to country’s entire population.
The idea was that each country would adapt the list based on their local disease prevalence, cost-effectiveness and other national priorities. And each country would determine the lowest-level health facilities expected to stock each essential medicine. To qualify as accessible, drugs were to be available and affordable.
But studies have shown that essential medicines used to treat non-communicable diseases are still poorly accessible to populations in low and middle income countries. The problem is that these are precisely where cases of non-communicable diseases such as cardiovascular disease, diabetes, chronic lung disease and mental health disorders are rising dramatically.
Uganda is a case in point. In our study we looked at the availability of 10 non-communicable disease medicines on Uganda’s essential medicines list. We found that out of close to 200 facilities, just under 40% had none of these medicines. And not a single facility stocked all the medicines on the list.
Yet Uganda, like most countries in the developing world, has seen an increasing burden of non-communicable diseases in the past 10 years. Just under a quarter of Ugandan adults suffer from high blood pressure and about 15% of Ugandans are overweight.
Our study shows that the health centres where medicines are free of charge, and should therefore be the most accessible, are the least likely to stock medicines for these chronic conditions. This means that people need to travel to referral centres just to obtain medicines for these increasingly common conditions.
To understand how medication was dispensed in Uganda we used data from a survey that the World Health Organisation encourages low and middle income countries to fill in annually. The survey looks at a variety of services that health facilities offer. These range from malaria testing to HIV counselling to availability of essential medicines to basic amenities such as running water and electricity.
The survey helps countries assess both their private and public health facilities.
In 2013, the last available data for Uganda at the time we conducted our study, the data included information gathered during spot checks done by surveyors. The checks involved looking at what was being kept on pharmacy shelves in health facilities and recording what was and wasn’t available. (While this method is widely used it is also not the most accurate, as pharmacy stockages are dynamic and fluctuate over time.)
The survey evaluated 20 essential medicines – 10 of which are used to treat non-communicable diseases. Not all of these medicines are expected to be stocked at every type of health facility all the time. For example, at the time of this study, the Uganda essential medicines list recommended that:
Metformin, a common diabetes medicine, was expected to be stocked at a level four health centre.
Nifedipine, a drug used to treat high blood pressure, was expected at a level three health centre
What we found was that:
Metformin was available in 79.4% of facilities expected to stock it, but
Nifedipine was only available at just under half of the expected facilities.
Beclomethasone, an inhaler for chronic lung diseases like asthma, was only available in 2.9% of expected facilities.
The lower level health facilities where the population is expected to receive primary health care, should be expected to stock essential medicines for a condition such as hypertension. But they don’t.
There were several other disparities we picked up, including:
Private-for-profit facilities had nearly twice as many available non-communicable diseases medicines as public facilities;
general hospitals had nearly twice as many available non-communicable diseases medicines as the lowest level facilities; and
Lower-level facilities – those that are closest to the population – are also the least likely to have these medicines available.
What this means is that people need to travel to referral centres just to obtain medicines for these increasingly common conditions. But even at the referral centres, availability remains sub-par.
Fixing the system
What our study shows is that health systems need to be strengthened with a focus on improving access to high quality, reliable services for increasingly common chronic conditions.
This will require investment in improving supply chains and better understanding the evolving demand for these medicines.