Abstract
BackgroundLack of access to essential medicines presents a significant threat to achieving universal health coverage (UHC) in sub-Saharan Africa. Although it is acknowledged that essential medicines policies do not rise and stay on the policy agenda solely through rational deliberation and consideration of technical merits, policy theory is rarely used to direct and guide analysis to inform future policy implementation. We used Kingdon’s model to analyse agenda setting for essential medicines policy in sub-Saharan Africa during the formative phase of the primary healthcare (PHC) concept.MethodsWe retrospectively analysed 49 published articles and 11 policy documents. We used selected search terms in EMBASE and MEDLINE electronic databases to identify relevant published studies. Policy documents were obtained through hand searching of selected websites. We also reviewed the timeline of essential medicines policy milestones contained in the Flagship Report, Medicines in Health Systems: Advancing access, affordability and appropriate use, released by WHO in 2014. Kingdon’s model was used as a lens to interpret the findings.ResultsWe found that unsustainable rise in drug expenditure, inequitable access to drugs and irrational use of drugs were considered as problems in the mid-1970s. As a policy response, the essential drugs concept was introduced. A window of opportunity presented when provision of essential drugs was identified as one of the eight components of PHC. During implementation, policy contradictions emerged as political and policy actors framed the problems and perceived the effectiveness of policy responses in a manner that was amenable to their own interests and objectives.ConclusionWe found that effective implementation of an essential medicines policy under PHC was constrained by prioritization of trade over public health in the politics stream, inadequate systems thinking in the policy stream and promotion of economic-oriented reforms in both the politics and policy streams. These lessons from the PHC era could prove useful in improving the approach to contemporary UHC policies.
Highlights
Lack of access to essential medicines presents a significant threat to achieving universal health coverage (UHC) in sub-Saharan Africa
A full scoping review was not conducted because the aim of the study is not to synthesize evidence but to apply Kingdon’s model to structure and explain the underlying factors that led essential medicines policy to emerge on the global agenda and how policy formulation evolved in sub-Saharan Africa
Using Kingdon’s model as a lens for interpretive analysis, we found that the essential medicines policy emerged under primary healthcare in response to the problems of unsustainable rise in medicine expenditure, pervasive inequities in global access to medicines and widespread irrational use
Summary
Lack of access to essential medicines presents a significant threat to achieving universal health coverage (UHC) in sub-Saharan Africa. The role of essential medicines in health systems has evolved tremendously, enjoying moments of favourable attention and episodes of policy uncertainty and controversy. These policy swings are driven by the interplay of institutions, ideas and interests in the political and policy domain. The geographical access to essential medicines reflects the structural determinants of inequality which raises the importance of the matter to the level of global politics [6] This makes access to medicines a matter of public policy; an issue where policy choices have consequences on immediate and long-term status of individuals and societies. Though the current terminology is medicines, the term drugs will be used for historical purposes
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