Abstract
Objective: Essential Medicines (EMs) are those that satisfy the priority health care needs of the population. Access to health care including EMs is a fundamental human right. In Ethiopia, studies designate the frequent drug shortages in public health facilities. Hence, this review aimed to assess and evaluate the national availability of essential medicines in Ethiopia.
Method: A systematic searching for all study designs which are published and/or reported from inception to August 27/2019 strategy was conducted in two literature databases (Google Scholar and PubMed. Additionally, references of related articles were searched using different search engines. Data qualities were assessed by abstracting the quality procedures taken in each individual’s studies and cross checked with Joanna Briggs Institute (JBI) quality appraisal criteria.
Results: A total of 256 studies, including duplicates, were primarily searched. Nine studies were met current study inclusion criteria. All included studies were published from 2003 to 2019 G.C. Consequently, reviewed studies conducted a total of 356 public and private drug outlets. All studies used cross-sectional study design. The most frequent concepts emerged in these documents were regarding availability and affordability of EMs (5 Articles), availability and pharmaceutical inventory management (3 Articles), one document on availability and price. The average national availability of EMs was precisely in public and private facilities scored about 70.16% and 70.1%, respectively. Results from the sub-national study indicate that, the national average stock out duration in primary health care facilities was 99.2 days, highest in Benishangul Gumuz (139 days). The most frequently reported stocked out drugs within the past 6-12 months at the time of study were; ORS, Amoxicillin syrup 125mg/5ml, Tetracycline eye ointment and tablet, Ergometrine injection in Adama and chloroquine syrup in Gondar. Whereas, carbamazepine 100mg/5ml syrup, diazepam 5mg/ml ampoule, gentamicin 20mg/2ml ampoule and ibuprofen 100mg/5ml suspension were not found in any drug outlets in both public and private sectors at the day of visit in West Wollega.
Conclusion: The finding of this review indicates the average national availability of essential medicines in Ethiopia is presently under the requirements of WHO recommendations. Moreover, the longer stockout period was also perceived in healthcare facilities. Thus, might need further attention of the respective stakeholders.
Keywords: Availability; Essential Medicine; Ethiopia
Abbreviations
EMs: Essential Medicines; EMCs: Essential Medicines for Children’s; EML: Essential Medicine List: ENMP: Ethiopian National Medicine Policy; FMAHCA: Food Medicine and Health Care Administration; FMOH: Federal Ministry of Health; HC: Health Center; JBI: Joanna Briggs Institute for Quality Appraisal; NCDs: Non-Communicable Diseases; PHCFs: Primary Health Care Facilities; RDS: Regional Drug Stores; PDROS: Private Drug Retail Outlets; TTEO: Tetracycline Eye Ointment; WHO: World Health Organization
Introduction
WHO defines Essential medicines as those satisfy the priority healthcare needs of the population. The first WHO essential drugs list was published in 1977, which described as a peaceful revolution in international public health [1]. The list helped to establish the principle that some medicines were more useful than others and that essential medicines were often inaccessible to many populations. Since then, the Essential Medicines List (EML) has increased in size; defining an EM has moved from an experience to an evidence-based process, including criteria such as public health relevance, efficacy, safety, and cost-effectiveness [2]. EMs are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford [3,4].
The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility [5]. Access to health care including EMs is a fundamental human right [6]. However, WHO estimates about onethird of the world’s population is without the access to medicines they need, typically in Asia and Africa [7]. WHO recommends at least 80% availability of essential medicines in healthcare facilities [3]. However, in low/middle income countries this is still a major challenge [8]. In a study conducted in 36 countries, average availability of essential medicines was reported to be 38% and 64% in the public and private sector, respectively [9].
In Ethiopia, despite a high burden of disease, utilization of health services remains very low, with people visiting a health facility less than once every two years [10]. There are frequent drug shortages in public health facilities. A national survey estimated that only 70% of key essential medicines were available in the public sector [11,12]. Unavailability of medicines in the public sector compels patients to revert to the private sector. Consequently, drugs can take up more than half of the actual cost of a visit, increasing the chance of incurring catastrophic health expenditures and the associated risks of falling into poverty [13].
Ethiopia has a national drug policy aimed to ensure adequate supply of medicines which are required for treatment of diseases affecting the majority of the country’s population [14], which gives the primary mandate to the government. To achieve this, the country developed national list of EMs based on the common health problems in the country starting from 1985 [15] which guides the decision of all health service providers with regard to selecting and availing the most needed medicines at every level of the healthcare system at all times with affordable cost [16]. Through its health and drug policies, the Government of Ethiopia has reaffirmed that the medicines used in health services within the nation shall be determined on the basis of the country’s major health problems and capabilities. Thus, to materialize this objective, it is necessary to select medicines which are required for promotion, prevention, diagnosis, treatment/mitigation and rehabilitation of diseases affecting majority of the population [16].
Data on the availability and affordability of EMs help managers and policy makers to develop national policy, regulations and strategies to enhance access to them. In Ethiopia, even though limited data availability regarding EMs in Ethiopia, reviewing and analyzing the existing individual studies would be valuable as much as it provides the summary of data for in sighting the government and other policy makers, and the scientific society about the current status of national availability of EMs in the country. Therefore, the aim of the current review is to assess the overall availability of essential medicine in the country from different studies in the country and also enables to identify the gaps for the future research areas.
Methods
Inclusion criteria
All articles and reports published in English language with all type of study designs and Ethiopian study settings were selected and included. Publication year of the articles were from the inception to 27/08/2019 G.C. Furthermore, studies done on public health facilities, private drug outlets, and other sectors of medicine outlets were selected. Studies on EMs and their empirical data on availability were included.
Exclusion criteria
Studies done outside Ethiopia. Documents discuss about general analysis/review, without empirical data; Guidelines; drug utilization patterns studies were also excluded.
Search strategy
A comprehensive literature search in PUBMED and Google Scholar was conducted using “mesh” terms like “essential medicine”, “availability of medicine”, “essential medicine in Ethiopia”, “Ethiopia” by combining them with Boolean operators; “AND’, “OR”. And “availability of medicine” by “All fields” from August 23 up to August 27, 2019 for articles published in English language from inception to August 27, 2019. Studies were first selected on the basis of their titles and the abstracts, and full texts were searched for those potentially fulfilling the inclusion criteria.
Data extraction
Data was extracted from included articles by the investigator using abstraction tables. Data points extracted included author, year of publication, types of study design used and methods of analysis, primary outcomes and the number of study facilities and the type of facilities/drug outlets were involved. Nine (9) articles were selected based on pre-determined inclusion and exclusion criteria. Articles were searched, identified, screened and selected from different search engines which are published in English language. Out of a total of 256 articles gained, 15 were from Google scholars, 238 were from PubMed and 3 were gained through hand searching.
Quality assessment
Individual studies were checked and assessed based on some of the checklists which recommended by Joanna Briggs Institute (JBI) quality appraisal criteria [17] adapted for studies reporting crosssectional such as: inclusion criteria; description of study subject and setting; valid and reliable measurement of interest; objective and standard criteria used; discussion of generalizability; identification of confounder; strategies to handle confounder; and appropriate statistical analysis (Table 1). Based on this, all documents were reviewed about their methodologies including sampling procedure, sample size selection, data collection methods and tools, number of selected essential drugs for surveying, criteria for selection of essential medicines, method of measurement of their availability and analysis, and outcomes values were abstracted by using tables (Table 2). All of them have their own standard procedures on the above respects on their methodological process. According to this, seven documents were checked for consistency and completeness of their data collection format at the end of the day by supervisors and data collectors. Data collection tools with incomplete data, wrong data collection on the specific medicine and not fulfilling the inclusion criteria were excluded during the time of analysis. However, two of the documents had no clearly mention about their quality management activity but, all have data collection methods which were based on interviewing the key informant (chief pharmacists) for both private and public pharmacies by using standard check list.
Name of Studies
Inclusion Criteria Used
Description of Study Subject and Setting
Valid and Reliable Measurement of Outcome
Objective and Standard Criteria Used
Discussion of Generalizability
Identification of Confounder
Strategies to Handle Confounder
Appropriate Statistical Analysis
Total N (%)
Level of Quality
Lemma, 2003, sub-national
1
1
1
1
1
0
0
1
6(75%)
High
Carasso, 2009, Amhara
1
1
1
1
1
0
0
1
6(75%)
High
Abiye, 2013, Jimma
1
1
1
1
1
1
1
1
8(100%)
High
Fentie, 2015, Gondar
1
1
1
1
1
0
0
1
8(75%)
High
Sado, 2016, West wollega
1
1
1
1
1
1
1
1
8(100%)
High
Tefery, 2016, sub-national
1
1
1
1
1
0
0
1
8(100%)
High
Abrha, 2018, Tigray
1
1
1
1
1
0
0
1
6(75%)
High
Gutema, 2018, A/A
1
1
1
1
1
1
1
1
8(100%)
High
Kefale, 2019, Adama
1
1
1
1
1
1
1
1
8(100%)
High
The score was ranges from 0 up to 1 and the score given “0” implies the lowest quality and “1” is the highest quality of a study with the respective standard criteria. Below 50% considered low quality, 50-75% medium quality and above 75% given high quality standard.
Table 1: Standard criteria used for the assessment and scoring the quality of included articles.
Methods of reporting
The Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guideline was used to report the result of this systematic review [18].
Data collection and handling
Each included individual studies were reviewed for the variable of interest and data were collected and handled by the abstraction table (Table 2).
Studies
Sampling Procedure
Sample Size
Data Collection Method and Tools
No of Selected Essential Medicines
Criteria for Selection of Medicines
Method of Analysis
Availability by Type of Outlets
Public Facilities
Private Drug Outlet
Other Sectors
Gutema, 2018, TASH
Selecting TASH as reference WHO/ HAI methodology
14 (5 from public and 9 from private sectors)
Standard checklist & interviewing chief pharmacist
13
Commonly prescribed antibiotics
WHO/HAI’s MS Excel, % facilities with specific drug
98.50%
92.30%
--
Sado, 2016, West Wollega
Random selection from random selected districts by WHO/ HAI methodology
58 (15 public, 41 private & 2 from other sectors) 1 from private and 2 of other sectors excluded
5 data collectors standard data collection format specific to the EMs
23 but 1 medicine excluded during the analysis due to incompleteness
WHO “Better Medicines for Children Project” & prevalent child illness
WHO/HAI’s MS Excel, % facilities with specific drug
43% low priced
42.8% low priced
Excluded, not fulfilling the WHO/HAI criteria
Fentie, 2015, Gondar
Primary health facilities in Gondar town
Totally 8 but 2 were excluded due to incompleteness
Standard check list form, by trained data collectors
26 tracer medicines
Ten top morbidities of the study area (adults and children).
Microsoft excels, average % of drugs in all facilities
23.67 (91%) during survey
--
--
Kefale, 2019 Adama
All HCs of Adama town
6 health centers
Observational checklist, by two trained druggists pretest, check for consistency
11 tracer medicines
Representativeness of EMs & expected to be found in HCs
SPSS 21.0 version average % of drugs in all facilities
76.4% during survey period
--
--
BS Carasso, 2009 Amhara
PHCs & PDOs 25 km away from the main road in the regional capital
Five public and 7 private outlets
Checklists and interview the key informant
12
Based on Leading cause of morbidity in the region
Epidata, % of outlets of availability of medicines
91%
90% (excluding antimalarial drug)
Abiye, 2013 Jimma
Jimma health center
1 health facility
Standard check lists, pretested, check for completeness
230
Based on list of drugs for health centers
Physical presence of EMs
55.65%
--
--
Tefery, 2013 Multi regional
6 regions of the country including Addis Ababa WHO/ HAI methodology
34 outlets public, 30 from private and 17 from other sectors
Check lists Data collectors worked in pairs, checked by supervisor training
25
6 were based on WHO/HAI global list & 19 on national importance
Physical presence of drugs during visit
64%
73%
76%
Lemma, 2003 Nation wide
Random selection of 5 regions from 9 regions, lottery method to select outlets from regions and Addis Ababa/ WHO/ HAI methodology
From Six region including AA, 111 PHCFs, 5 RDSs, & 24 PDROs
Standard Check lists training for super. & data 6 collectors/checked for consistency & completeness
12 key essential drugs
Used to treat the most common health problems in the country,
Physical presence of drugs during visit /excel 2002
70% in PHCFs and 85% in RDS
91%
--
Abrreha, 2018 Mekele
WHO/ HAI methodology by selecting the main public hospital in Mekele
10 public, 31 private and 2 nonprofits
Standard data collection format by trained pharmacists. Checked for completeness &consistency.
27
List of “Priority life-saving medicines for women and children” developed by WHO in 2012
Physical presence at the day for visit
41.90%
31.50%
--
The hyphen (--) indicates not studied facilities or excluded due to study’s inclusion criteria.
Table 2: Summary of general characteristics of individual studies included for the systematic review.
Data analysis
All collected data on the variable of interest across nine documents would be analyzed by using Microsoft Excel 2016. Results would be presented by using tables and charts.
Results
Initially a total of 253 articles were searched from PubMed and Google scholars and 3 other additional articles were found by hand searching using article references.
During the screening process, 20 articles were removed due to duplication and 200 articles were excluded due to title irrelevance or do not meet the inclusion criteria. From 36 eligible articles, full document assessments were done to check whether the interest variable was empirically included and among these 27 articles were excluded and finally 9 articles were included for the final review (Figure 1). The most frequent concepts that emerged in these documents were: about availability and affordability of Ems (5 documents), availability and pharmaceutical inventory management (3 documents), one document on availability and price. 2 studies assess the availability of essential medicines sub-nationally i.e., in six regions of the country, while two studies assess the availability of selected essential medicines for children in Tigray region and West Wollega, whereas the rest were done on limited number of public and private facilities in a specific setting. However, the studies were touching most regions of the country except Somali, Diredewa and Gambella [8,15,19-23].
Figure 1: Flow chart of the selection process of articles for the review.
All included studies were cross sectional and found published between 2003 up to 2019 but 7 of the articles were emerged from 2013. This indicates that despite of the inclusion criteria starts from the inception, almost all of them were recent and which helps us to have a recent understanding on the current status of medicine availability in our country. The studies conducted in a total of 356 facilities and grouped by the type of facility; 193 public facilities (hospital pharmacies, health centers, health stations), 5 regional drug stores owned by PHARMID at a time, 110 private drug outlets and 17 from other sector facilities (municipality pharmacies, Red Cross health facilities, Family Guidance Association health facility and NGO health facilities). Table below shows the summery of data on the reviewed articles in the chronological order of year of publication. Based on this finding Average availability of essential drugs in the nine articles (Table 3) varied between 41.9% (Tigray region) and 98.5% (Addis Ababa) in public facilities and similarly, in private 31.5% and 98.2% with the above respective areas.
Name of Studies
Place of Study
Study Design
Sample Size
Method of Sampling
Number of Selected Ems
Average Availability by (%)
Public
Private
Other Sectors
Lemma, 2003
Sub-national (six regions)*
Cross sectional
111 PHCFs, 5 RDSs, &24 PDROs
Stratified sampling method
12
70
91
Not studied
Carasso, 2009
Amhara
Cross sectional
Five public PHC and 7 privates
Systematic selection
12
91
90
“
Abiye, 2013
Jimma
Cross sectional
1 health center
Purposive as the main health center
230
55.65
--
“
Fentie, 2015
Gondar
Cross sectional
Six health centers
All health centers of Gondar town
26
91
--
“
Sado, 2016
West Wollega
Cross sectional
55 (15 public, 40 private)
WHO/HAI methodology
22 (Children)
43
42.8
“
Tefery, 2016
Sub-national (six regions)*
Cross sectional
34 outlets public, 30 from private and 17 from other sectors
WHO/HAI methodology
25
64
73
76
Abrha, 2018
Tigray
Cross sectional
10 public, 31 privates
WHO/HAI methodology
27 (Children)
41.9
31.5
“
Gutema, 2018
Addis Ababa
Cross sectional
14 (5 from public and 9 from private sectors)
WHO/HAI methodology
13
98.5
92.3
“
Kefale, 2019
Adama
Cross sectional
Six health centers
All HCs of Adama town
11
76.4
“
Total Average Availability
70.16
70.1
76
*Sub-national for two studies implies places. For Lemma, 2003 (Tigray, Amhara, Oromia, Southern Nations, Nationalities, and Peoples' Region (SNNPR), Addis Ababa, Bennshangul gumz) and for Tefery, 2016 (Addis Ababa, Oromyya/Adama, Amhara, SNNPR, Harari and Afar).
Table 3: Summary of each study characteristics on availability of essential medicines at the day of visit.
Half of the studies select their essential medicines to include on the study check list based on leading cause of morbidity in the study area [11,14,15,20]. Whereas, some were conducted on the health centers were select based on the representativeness and expected to be found in HCs [21,23] and others were based on commonly prescribed antibiotics, WHO “Better Medicines for Children Project”; priority lifesaving medicines for under-five children by WHO; and overall national importance [8,14,19].
As shown from the Figure 2, studies from three places namely, Addis Ababa, Gondar and rural health facilities from Amhara region shows better availability of medicines both in public and private outlets. But there is still lower report of availability in Tigray, West wollega and Jimma.
Figure 2: Availability of medicines in each type of facility and place.
From the report of all documents, the total average percentage availability of public facilities from all articles and private facilities from six articles were almost equal i.e., 70.16% and 70.1% respectively (Figure 3). However, two sub-national studies conducted on relatively larger sample size facilities showed that private facilities had much better availability than public facilities [14,24].
Figure 3: Average (%) availability by the type of facility.
To measure the historical availability of essential drugs to treat common health problems, a retrospective survey was undertaken by three studies (one sub-national and two were in Gondar and Adama) by reviewing the stock cards of the facilities covering a period of 6-12 months [14,15,21]. Results From the sub-national study indicate that, the national average stock out duration in Primary Health Care Facilities (PHCFs) was 99.2 days and highest in Benishangul Gumuz (139 days). The average stock out duration for Gondar and Adama health centers were 30.5 and 72.9 days respectively [15,21]. The most frequently reported stocked out drugs within the past 6-12 months were; ORS, Amoxicillin syrup 125mg/5ml, Tetracycline Eye Ointment (TTEO), FEFOL tab and Ergometrine injection in Adama and chloroquine syrup in Gondar [15,19,21]. Whereas, carbamazepine 100mg/5ml syrup, diazepam 5mg/ml ampoule, gentamicin 20mg/2ml ampoule and ibuprofen 100mg/5ml suspension were not found in any drug outlets in both public and private sectors at the day of visit in West Wollega [20].
Discussion
Studies indicate that the concept of EMs has significantly reduced morbidity and mortality in many countries of the world in the past 30 years, particularly in developing countries [25]. So, the aim of this review is primarily to assess and evaluate the national availability of EMs in Ethiopia based on the studies available across the country. To the best of my knowledge, there was no review on availability studies in Ethiopia till this time so; this systematic review provides the first comprehensive assessment of essential medicine availability in the country based on the WHO recommendations criterions and prevalent disease across the country.
This review reported that the overall average availability of EMs was below the requirement level which might be an indicative of a substantial challenge in clinical practice in the country especially on pediatrics managements. The national average availability of selected EMs across the study both in public and private facilities was 70.167% and 70.1% respectively. This finding was far apart from the WHO recommendation, availability of EMs should be 100% [26] and still below the minimum requirement of WHO (80%) to be available in public facilities [27]. However, it is higher than a study conducted in 36 countries; average availability of essential medicines was reported to be 38% and 64% in the public and private sector, respectively [4] and still higher from mean availability of essential medicines of the public sector in 24 countries around the globe [28].
Studies on availability of children EMs shows still below 50% ranges from (31.5%-43%) both in public and private facilities. This may due to factors like poor availability of pediatric dosage formulation in the facility and lack of focus from the government policy. The finding on this regard has similar in ranges with studies done in Australia (38%), New Zealand (35%) but slightly less than from the percentages found in the United Kingdom (59%), USA (54%) and Netherlands (48%) [29-34] and comparable to a study conducted on the availability and prices of the WHO’s EMs for children in Guatemala revealed that availability of EMs is less than 50% in both private and public sector [3]. This confirms that the limited availability of medicines for children is a global rather than regional problem. However, data comparison of all these studies should, be considered in view of methodological difference. Studies suggest that government and private drug outlet organizations should strengthen activities to increase availability of EMs like; promoting competition for lower-cost on the market efficient government procurement such as buying lower-priced quality-assured generics, negotiating prices with suppliers eliminating stock-outs through adequate forecasting, adequate and sustainable financing, Efficient distribution, and eliminating taxes and tariffs on essential medicines [5]. It was noted that, even though the nature of study affects the type of study designs to be used, all studies were used cross sectional study designs and their quality could be considered low according to their weak designs. On the other hand, included literatures were from PubMed and Google scholars. So, studies which are not indexed to these databases were not included in the study which may lead us to a suspicious on publication bias. The other limitation was availability on this review refers to the day of data collection which did not reflect availability over time, although it does reflect the situation people experience when going to facilities.
Conclusion
The review was done from nine studies conducted in a total of 356 public and private facilities from which the overall average percentage availability was almost equal which is 70.16 in public and 70.1 in private facilities. The finding indicates that the availability is low compared with the WHO recommendations minimum requirements i.e., 80%. Based on this finding Average availability of essential drugs in the nine articles varied between 41.9% (Tigray region) and 98.5% (Addis Ababa) in public facilities and it is slightly wider in private facilities which ranges from 31.5% up to 98.2% with the above respective areas. Studies from three places namely, Addis Ababa, Gondar and rural health facilities from Amhara region shows better availability of medicines both in public and private outlets. But there is still lower report of availability in Tigray, West Wollega and Jimma. Despite of its global wide problem, two studies on children’s essential medicine reported that the availability was significantly law ranges from (31.5-43%) which needs an attention of any stake holders as an alarming problem.
As a result, identifying and analyzing the potential factors affecting the availability of essential medicines will be necessary for not only has the low resulted of this review but also to have reach information on the gap for launching strategic solution for the problem. So, the government of Ethiopia, academic institutions and other researchers should consider this gap for their future research areas.
Declaration
Authors’ contributions: DT designed the study. DT and GA collected scientific studies, assessed the quality of the study, extracted and analyzed the data. WA commented on the review. GA also prepared the manuscript for publication. All authors have read and approved the manuscript.
Availability of data and materials: All data generated and analyzed during this study are included in this published article and publicly available.
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