Affordable Medicines Research Articles

Revisiting the issue of access to medicines in Africa: Challenges and recommendations

AbstractBackgroundAccess to safe, effective, affordable, and quality medicines is an essential component of the right to health and is also one of the targets in the global development agenda. In this review article, we extensively discuss the challenges and issues surrounding access to medicines in the African region as well as provides recommendations for ensuring medicines security on the continent.MethodsWe conducted narrative review with the use of data reported in published literature, reports, and grey literature available in African countries on topics pertaining access to medicines. The authors also snowballed further data to gather information for this review and narrative synthesis was conducted.ResultsAfrica faces a double burden of infectious and non‐communicable diseases and the need for effective universal access to medicines cannot be deemphasized. However, access to medicines on the continent is not without issues and challenges. Some of which are the high burden of infectious diseases and non‐infectious diseases, limited pharmaceutical industries and high costs of raw materials, overdependence on countries abroad for medicines, poor supply chain systems, lack of government investment in the pharmaceutical sector, unfavourable manufacturing conditions, limited health workforce, lack of sustainable health financing mechanisms, lack of infrastructures and technical know‐how, low investment on research and development, and circulation of fake and counterfeit medicines among others.ConclusionThis review reifies that access to medicines in Africa faces numerous challenges and it emphasizes the urgent need to address these issues as the continent geared towards strengthening its health systems for universal health coverage.

Kiran Mazumdar-Shaw: the woman behind the success of Biocon

Study level/applicability This case is meant for MBA/MS/executive MBA students. Subject area Entrepreneurship development, leadership. Case overview This case is about the successful entrepreneurial journey of Kiran Mazumdar-Shaw, founder of India-based biotechnology company Biocon Limited. Mazumdar-Shaw established Biocon in 1978 as a joint venture company. As a woman entrepreneur, Mazumdar-Shaw faced many challenges and setbacks during her initial days. She overcame these and took Biocon to new heights. Later, Mazumdar-Shaw decided to make a strategic shift in Biocon’s business model – going from manufacturing enzymes to biopharmaceuticals with the vision of making an impact on global health care by providing access to affordable, life-saving drugs. Expected learning outcomes The learning outcomes are as follows: understand the ecosystem of women entrepreneurs in developing countries; examine the challenges faced by women entrepreneurs in their entrepreneurial journey and how successful entrepreneurs convert challenges into opportunities; and analyze what entrepreneurial leadership is and understand how these leadership qualities play an important role in the success of entrepreneurial ventures. Social implications Mazumdar-Shaw was able to break through the gender barrier that was highly prevalent in Indian society then and successfully established her entrepreneurial venture in biotechnology, a discipline that was still nascent in the1970s. Though she has scaled great heights in the biotechnology area and developed her business, she has remained sensitive to the problems of those who are unable to get affordable medicines. Firmly believing that she should share the prosperity of the company with the poor and the marginalized, Mazumdar-Shaw, through her philanthropic venture, Biocon Foundation, started providing essential drugs at affordable prices to them. Subject code CCS 3: Entrepreneurship.

Jan Aushadi Scheme: A crucial step towards achieving health equity

Health Equity is a widely acknowledged policy objective for all responsible governments around the world. Equity refers to “equal access to available care for equal need, equal utilization for equal need, and equal quality of care for all” (Whitehead, 1992). Simply put, Health Equity is about ensuring that every person has the chance to be as healthy as possible. In this context, access to affordable medicines becomes a crucial component towards attaining equity, as even today, drugs constitute a high proportion of out-of-pocket (OOP) expenses, often causing untold financial hardships for most households.

Jan Aushadi Scheme: A crucial step towards achieving health equity

Health Equity is a widely acknowledged policy objective for all responsible governments around the world. Equity refers to “equal access to available care for equal need, equal utilization for equal need, and equal quality of care for all” (Whitehead, 1992). Simply put, Health Equity is about ensuring that every person has the chance to be as healthy as possible. In this context, access to affordable medicines becomes a crucial component towards attaining equity, as even today, drugs constitute a high proportion of out-of-pocket (OOP) expenses, often causing untold financial hardships for most households.

Powers, engagements and resultant influences over the design and implementation of medicine pricing policies in Ghana

IntroductionUniversal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences...

Psychosocial assessment among ophthalmic patients attending tertiary eye care centre during the lockdown in times of COVID-19 pandemic.

Purpose:The coronavirus disease (COVID-19) pandemic continues to play havoc in our lives. During the first “ lockdown” in 2020, we were keen on assessing the anxiety levels of patients who sought ophthalmic care despite the lockdown. Public health actions, such as social distancing, were necessary to reduce the spread of COVID-19. As a result, most people felt isolated and lonely, thereby causing increased levels of stress and anxiety in them. We aimed to assess the anxiety levels using the Hamilton Anxiety Scale and personality assessment using the 57-point Eysenck’s Personality Inventory (EPI) questionnaire among patients visiting a tertiary eye care hospital during the lockdown period.Methods:Consecutive patients attending an ophthalmic tertiary care hospital during the COVID-19 pandemic and lockdown were approached to be a part of this prospective cross-sectional survey.Results:In total, 1,088 responses were analyzed during the 2-month study period with the mean age being 45.7 + 16.9 years. The majority had completed graduation (78%) with 15 years or more of formal education. The purpose of the visit was an emergency consultation in 42% (n = 455), a review appointment in 42% (n = 457), and the remaining (16%, n = 176) came for a routine consultation. The majority of the patients (>90%) did not report experiencing any of the 14 sets of symptoms. A mild level of anxiety was noted in 1,086 (>99%) respondents, whereas only 2 (<1%) respondents showed mild–moderate levels of anxiety. Financial concerns such as affordability of medications (6% vs. 3%, P = 0.05) and fear of losing their job (16% vs. 11%, P = 0.02) were significantly more in those experiencing any anxiety compared to those with no anxiety.Conclusion:Our study revealed that patients visiting a tertiary ophthalmic center during lockdown were graduates, sought eye consultation primarily for emergency or a review, and had no major anxiety symptoms. In those with anxiety, the affordability of medicines and loss of jobs were the main concerns.

Analysis of antiasthmatic drugs for inhalation in the pharmaceutical market of Ukraine and dynamics of their consumption

Bronchial asthma (BA) is a common disease, as today the world suffers from about 300 million people. The number of patients with severe and complicated forms of BA is growing every year due to untimely diagnosis of the disease and late appointment of basic therapy. Complications cause disability in patients and increase mortality.&#x0D; The purpose of this work was to study the range and consumption in Ukraine of antiasthmatic drugs for inhalation (ADI), intended for the treatment of BA for the period 2018–2020.&#x0D; The analysis of the range and volumes of consumption of ADI was carried out according to the system of research of the market of medicines «Pharmstandard» of the company «Morion». Consumption estimates were made using the ATC/DDD methodology. DDDs/1 000 inhabitants/day (DID, DDDs per 1 000 inhabitants per day) was used as a unit of measurement.&#x0D; The results showed that in the pharmaceutical market of Ukraine during 2018–2020 used 61–64 trade names (TN) ADI, of which 11–13 TN were domestically produced and 50–51 TN – foreign manufacturers. Retail prices for ADI during 2018–2020 varied widely and increased slightly each year, due to economic instability in the pharmaceutical market of Ukraine. It was found that the consumption of ADI in the period 2018–2019 increased slightly by 1.03 times – from 7.00 DID in 2018 to 7.24 DID in 2019. In 2020, the consumption of this group of drugs decreased 1.1 times – to 6.60 DID. The undisputed leader in consumption in Ukraine was salbutamol (3.53–3.56 DID), which is probably due to the clinical efficacy and sufficient safety of the drug, greater availability of salbutamol for the population due to the wide range of generic drugs in Ukraine. market and the state program «Affordable Medicines». The second place was taken by the combination of fenoterol + ipratropium bromide (0.81–0.85 DID), which is used in adults and children for the immediate treatment of sudden attacks of bronchospasm in BA. The third place in terms of consumption in Ukraine was occupied by the combination of salmeterol + fluticasone (0.52–0.54 DID), which is mainly prescribed to patients with moderate and severe asthma.

Analysis of centralized public procurement of medicines in Ukraine with the involvement of international organizations

The Ministry of Health of Ukraine carries out centralized procurement of drugs in 40 priority areas with the involvement of international organizations «UNDP», «UNICEF» and «Crown Agents» and regional procurement from local budgets and the reimbursement program «Affordable medicines».This procedure increases drugs accessibility, medical care quality and pharmaceutical provision of the population.&#x0D; The aim of the work is analyze the current state and effectiveness of centralized drugs procurement through the Ministry of Health in Ukraine.&#x0D; The object of research is the data of official statistics, regulations, scientific publications, public module of analytics programm VI ProZorro. The research was conducted using methods of content-analysis, systematization and generalization.&#x0D; Analysis of the dynamics of procurement of drugs involving the Ministry of Health in 2018‒2020 revealed a trend of increasing the amount of budget funds provided for the purchase of drugs in 2020 by 60% compared in 2018. In 2020, 14 procurement programs were transferred State Enterprise «Medical Procurement of Ukraine», they were performed using the electronic system «ProZorro» with the participation of a large number of international drug companies.&#x0D; A comparative analysis of drugs prices purchased in 2017‒2020 in the fields of «Children's Oncology» and «Adult Oncology». The decrease in drugs prices is due to competition and direct participation of drug manufacturers in tenders; entering the market of new generics, introduction of transparent mechanisms of electronic auctions, etc. Some drugs in 2020 were purchased in higher prices due to lower order volumes; quarantine restrictions, including import restrictions; rising prices for substances for the manufacture of drugs.&#x0D; Centralized procurement of drugs and medical commodities in Ukraine is carried out by the Ministry of Health with the involvement of international organizations «UNDP», «UNICEF» and «Crown Agents». These are temporary measures implemented in 2015 in connection with the reform of the public procurement system, aimed at reducing corruption risks and improving the pharmaceutical supply of the population. Such purchases are made in 40 fields, the total amount is about UAH 6 billion per year.&#x0D; Involvement of international organizations in centralized public procurement of medicines in Ukraine and implementation of a reimbursement program for medicines, including for the treatment of cardiovascular diseases reduces the price and ensures the availability of drugs for the population.

Evaluating the Price, Availability, and Affordability of Essential Medicines in Primary Healthcare Institutions: A Mixed Longitudinal and Cross-Sectional Study in Jiangsu, China.

ObjectiveThis study aimed to evaluate the price, availability, and affordability of essential medicines in primary healthcare institutions in Jiangsu Province.MethodsA mixed longitudinal and cross-sectional survey was conducted in primary healthcare institutions in Jiangsu based on the adjusted World Health Organization and Health Action International methodology. 45 essential medicines were collected from 30 primary healthcare institutions in Nanjing from 2016 to 2020. We also collected information on these medicines in 70 primary healthcare institutions across seven cities of Jiangsu in 2021. The availability, price, and affordability were compared with matched sets. Differences of availability between years and cities were further compared using Wilcoxon rank-sum test.ResultsIn Nanjing, the variation was significant of availability during the study period. The MPR was generally decreasing between 2016 and 2020, with the median price ratio (MPR) for lowest-priced generics (LPGs) ranging from 1.20 to 2.53 and originator brands (OBs) substantially above international levels. The median availability of generic medicines increased in 2018 and subsequently stabilized at around 55%, and the availability of originator medicines was low. There were no significant regional differences in prices across the sampled cities in Jiangsu, and the median MPR for LPGs was acceptable (1.23), while the median MPR for OBs was 8.54. The mean availability was different across regions (p < 0.001), being higher in Nanjing (54.67%) and Nantong (56.22%), and lower in northern Jiangsu (about 35%). For LPGs, there was little difference in the proportion of medicines with low availability and high affordability (50.00% for urban residents and 40.48% for rural residents). For OBs, there were more than half of rural residents had low availability and low affordability of medicines (58.82%).ConclusionsIn terms of yearly changes, the prices of essential medicines have considerably decreased, and the availability of LPGs has slightly increased. However, the availability of medicines was found to be poor and there were regional differences in the availability and affordability of medicines among metropolitan and rural areas. Policy interventions targeting external factors associated with health resource allocation are essential and possible strategies include effective and efficient government investment mechanisms on primary healthcare.

Universal Health Coverage; A Way Forward

Universal health coverage means every person has access to quality health care without suffering financial hardships. The basis of universal health coverage lies in the primary health care concept, which was envisioned way back in 1978, as mentioned in Alma Ata Declaration1. The "World Health Report" published by the World Health Organization (WHO) in 2008 structures primary health care reforms in four groups. One of the crucial reforms was universal coverage reform to improve health equity2. WHO and UNICEF in 2018 documented how primary health care will be in the 21st century? The approach was towards universal health coverage and sustainable development goals. Sustainable development goals were to be achieved by 2030, and they were a continuation of millennium development goals 2000–20153. The resolution on Transforming our world: the 2030 Agenda for Sustainable Development adopted the target of universal health coverage by 2030, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all4. Currently, many developing nations do not have access to health services. About 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health. To make health for all, we need individuals and communities to have high-quality health services to take care of their families health. Skilled health workers providing quality, people-centred care and policy-makers should be committed to investing in universal health coverage. Universal health coverage should be based on intense, people-centred primary health care. Good health systems are rooted in the communities they serve. They focus not only on preventing and treating disease and illness but also on helping to improve well-being and quality of life5. Pakistan, the developing country, is struggling to provide good quality health services, mostly availed from the out-of-pocket expenditure.&#x0D; Both private and public sector hospitals were trying to deliver health services, but poor people failed to have access to many services due to poverty. To overcome this obstacle and address indicator 3.8 of SDGs, the current government developed a five-year program to improve the targeted population's health by increasing their access to quality health services. The initiative will also reduce poverty, as the government will cover most of their health budget through the "Sehat Sahulat Program". The program was part of the National vision to ensure Universal Health Coverage (UHC) for all Pakistani families. No one is denied quality healthcare services only because of financial constraints. Initially, it was piloted in selected four districts of Khyber Pakhtunkhwa, which was later extended to all over the province. Currently, 7.2 million families are getting free in-patient health care services, and the program's annual cost is 18 billion. It was a bold initiative of the current government, which helped improve access to UHC, thus addressing one of the sustainable development goals6,7.

The Impact of Two-Invoice System on Pharmaceutical Manufacturers' Selling Expenses in China: A Difference-in-Differences Approach.

A perennial question for the pharmaceutical industry has been excessive drug prices. To alleviate patients’ burden of expensive medical bills and increase the affordability of medicines, China adopted the Two-Invoice System (TIS) in drug procurement for public medical institutions in 2017. In this paper, we study the impact of the TIS on pharmaceutical manufacturers’ selling expenses. Using a Difference-in-Differences (DID) methodology and a sample of the A-share pharmaceutical manufacturing firms listed on the Shanghai Stock Exchange and Shenzhen Stock Exchange from the years 2014 to 2020, we find that the TIS leads to a significant increase in pharmaceutical manufacturers’ selling expenses but gradually weakens over time. In addition, we further explore whether the impact of the TIS on pharmaceutical manufacturers’ selling expenses is affected by the pharmaceutical manufacturers’ previous drug circulation mode. The results indicate that the TIS could significantly increase the pharmaceutical manufacturers’ selling expenses in the agency mode group. However, there is no evidence to support the TIS having the same effect in the direct sales office model group.

CERTAIN ASPECTS OF LEGAL REGULATION OF THE SINGLE MEDICAL SPACE OF UKRAINE

The author analyzes the legislative regulation and doctrinal provisions on the single medical space of Ukraine. Emphasis is placed on the relevance of the study on the creation of a single medical space in Ukraine, taking into account the course of implementing the best internationally recognized mechanisms and standards in the field of health care in the established domestic system. Problematic aspects of main definitions in the field of legal regulation of the single medical space of Ukraine are considered. It is concluded that the single medical space of Ukraine should be a guarantee of affordable and quality medicine, and the basic requirements of the law to all its functional components should be unified and enshrined in the relevant regulations.

Providing access to high-quality, low-cost medicines across low and middle-income countries (LMICs), working with governments and generic manufacturers around the globe - A business case.

Gilead Sciences, under Dr. John Martin's leadership, created its Global Access Program to deliver high-quality, affordable medicines to treat and ultimately eliminate some of the world's most challenging-to-treat, pervasive, life-limiting diseases not as philanthropy but based on a self-sustaining business model-a highly novel concept in the pharmaceutical realm. John was determined to bring together all key stakeholders from public health officials to doctors and patients around the globe to understand barriers and opportunities in HIV, viral hepatitis, and visceral leishmaniasis (VL) and in so doing, pushed the Gilead team to devise novel strategies to address healthcare disparities in resource-challenged geographies. This case study provides an overview of the evolution and impact of the Gilead Access to Medicines Program in providing treatments for HIV in low- and lower middle-income countries.

Results of medical and economic efficiency assessment of the gastroduodenite prevention program for retirement age patients with essential arterial hypertension, which took part in the program "Affordable medicines"

The medical and economic effectiveness of approaches to the prevention of gastroduodenitis in patients of retirement age with essential hypertension has been insufficiently studied. This fact necessitated this study. A combined (retrospective-prospective) study of gastroduodenitis prevention programs for retirement age patients with essential hypertension who are taking drugs under the "Affordable Medicines" program was conducted. A new theoretical model for assessing the medical and economic effectiveness of the gastroduodenitis prevention program in patients with essential hypertension with key parameters "incremental cost – effectiveness ratio" (ICER) and "incremental benefit – cost ratio" (IBCR) has been developed. The effectiveness of the proposed program was evaluated. The main factors of lifestyle and treatment that affect the development and exacerbation of gastroduodenitis in this category of patients are identified. The risks of gastroduodenitis due to non-steroidal anti-inflammatory drugs, the presence and absence of compliance, age and sex of patients, living alone (without a family), which indicate ways to improve prevention programs and determine the nature of recommendations for patients on lifestyle and treatment of hypertension. Evaluation of the effectiveness of the proposed prevention program on the criteria of ICER and IBCR allowed to determine the positive additional effect of participation in the reimbursement program, compliance, male gender, identified patient income levels at which increasing costs of prevention programs has greater economic effect. It is recommended to use the results of the study to improve the programs of prevention of hypertension in patients with hypertension at the stage of primary health care, including the cost of individual items of expenditure of the program "Affordable Medicines". Keywords: prevention program, risk, clinical and economic evaluation, costs-effectiveness, essential hypertension, gastroduodenitis.

"Ready for the future?" - Status of national and cross-country horizon scanning systems for medicines in European countries.

Background: Horizon scanning aims to systematically identify upcoming health technologies and thus allows policy-makers to be better prepared for the entry of new medicines with possibly high price tags into the national health system. The aim of this study is to survey the existence of national and cross-national horizon scanning systems for medicines in European countries.Methods: Experts working in public authorities (members of the Pharmaceutical Pricing and Reimbursement Information/PPRI network) in the WHO European region participated in surveys in 2014 and 2019 and informed about the status of horizon scanning in their country (response rate: 14 and 44 countries, respectively). Identified advanced horizon scanning systems as of 2019 were further investigated based on a literature review.Results: In 2019, six countries (Iceland, Italy, the Netherlands, Norway, Sweden, United Kingdom) reported systematic use of horizon scanning for some new medicines, and four countries (Austria, Denmark, France, Ireland) had some horizon scanning activities ongoing. No systematic use of horizon scanning was reported from the remaining 34 countries. The findings of the survey undertaken five years earlier were similar, with even fewer systems in place. A recent development is the establishment of cross-country initiatives of governments that aim, among others, to jointly perform horizon scanning; the International Horizon Scanning Initiative (IHSI) initiated by the Beneluxa collaboration is the most advanced undertaking in this respect. Countries with systematic use tend to have horizon scanning fully integrated in a system for the management of new medicines, and they use horizon scanning outcomes to inform decisions as to whether or not a Health Technology Assessment will be conducted and price negotiations be started. Differences between existing horizon scanning systems mainly concern the timings of scanning and reporting, the sources for the inputs and the accessibility of the findings.Conclusion: There appears to be a discrepancy between the perceived importance of horizon scanning based on some eye-opening examples in the past and its actual implementation in European health systems. The latter is likely attributable to horizon scanning being resource-intensive. The establishment of new national and international horizon scanning systems offers the opportunity to investigate their impact on sustainable access to affordable medicines from the start.

Cyber risks to Ukrainian and other health systems

Cyber risks to Ukrainian and other health systems

The role of social protection of pharmacies and social satisfaction of pharmacy visitor

The modern pharmaceutical industry is becoming one of the fastest growing areas in the industry. The main task of pharmacies at the present stage of economic development is not only to make a profit, but, first of all, to perform a social function in providing high-quality and affordable medicines to the population of the country. Since pharmacy has a social orientation, special attention is paid to the issue of forming an assortment of drugs, taking into account the solvency of the population and optimizing the provision of certain pharmaceutical remedies. It has been proven that a well-formed assortment of drugs and medical devices increases the rate of inventory turnover, which significantly affects the efficiency of a pharmacy.

Factors associated with the availability and affordability of essential cardiovascular disease medicines in low- and middle-income countries: A systematic review.

Despite their potential to prevent or delay the onset and progression of cardiovascular disease (CVD), medicines for CVD remain unavailable and unaffordable to many in low- and middle-income countries (LMICs). We systematically reviewed the literature to identify factors associated with availability and affordability of CVD medicines in LMICs. A protocol for this study was registered on the PROSPERO register of systematic reviews (CRD42019135393). We searched Medline, EMBASE, Global Health, Cumulative Index to Nursing and Allied Health Literature, EconLit, Social Policy and Practice, and Africa Wide Information for studies analyzing factors associated with the presence of medicines (availability) or the price of these medicines as it relates to ability to pay (affordability) in LMICs. We performed a narrative synthesis of the results using an access to medicines framework that examines influences at different levels of the health system. We did not conduct a meta-analysis because of the differences in analytic approaches and outcome measures in different studies. The search was conducted in accordance with PRISMA guidelines. Of 43 studies meeting inclusion criteria, 41 were cross-sectional. Availability and affordability were defined and measured in different ways. A range of factors such as sociodemographic characteristics, facility tier, presence of medicines on national essential medicine lists, and international subsidy programs were examined. The studies had variable quality and findings were often inconsistent. We find gaps in the literature on factors associated with availability and affordability of CVD medicines, particularly at the health program level. We conclude that there is a need for experimental and quasi-experimental studies that could identify causal factors and effective responses. Such studies would help further our understanding of how complex multifactorial influences impact these outcomes, which could inform policy decisions. Along with this, greater standardization of definitions and measurement approaches of availability and affordability are needed to allow for more effective comparisons.

Proof of Concept in Artificial-Intelligence-Based Wearable Gait Monitoring for Parkinson's Disease Management Optimization.

Parkinson’s disease (PD) is the second most common progressive neurodegenerative disorder, affecting 6.2 million patients and causing disability and decreased quality of life. The research is oriented nowadays toward artificial intelligence (AI)-based wearables for early diagnosis and long-term PD monitoring. Our primary objective is the monitoring and assessment of gait in PD patients. We propose a wearable physiograph for qualitative and quantitative gait assessment, which performs bilateral tracking of the foot biomechanics and unilateral tracking of arm balance. Gait patterns are assessed by means of correlation. The surface plot of a correlation coefficient matrix, generated from the recorded signals, is classified using convolutional neural networks into physiological or PD-specific gait. The novelty is given by the proposed AI-based decisional support procedure for gait assessment. A proof of concept of the proposed physiograph is validated in a clinical environment on five patients and five healthy controls, proving to be a feasible solution for ubiquitous gait monitoring and assessment in PD. PD management demonstrates the complexity of the human body. A platform empowering multidisciplinary, AI-evidence-based decision support assessments for optimal dosing between drug and non-drug therapy could lay the foundation for affordable precision medicine.

No impact of performance-based financing on the availability of essential medicines in Burkina Faso: A mixed-methods study.

Access to safe, effective, and affordable essential medicines (EM) is critical to quality health services and as such has played a key role in innovative health system strengthening approaches such as Performance-based Financing (PBF). Available literature indicates that PBF can improve EM availability, but has not done so consistently in the past. Qualitative explorations of the reasons are yet scarce. We contribute to expanding the literature by estimating the impact of PBF on EM availability and stockout in Burkina Faso and investigating mechanisms of and barriers to change. The study used an explanatory mixed methods design. The quantitative study component followed a quasi-experimental design (difference-in-differences), comparing how EM availability and stockout had changed three years after implementation in 12 PBF and in 12 control districts. Qualitative data was collected from purposely selected policy and implementation stakeholders at all levels of the health system and community, using in-depth interviews and focus group discussions, and explored using deductive coding and thematic analysis. We found no impact of PBF on EM availability and stockouts in the quantitative data. Qualitative narratives converge in that EM supply had increased as a result of PBF, albeit not fully satisfactorily and sustainably so. Reasons include persisting contextual challenges, most importantly a public medicine procurement monopoly; design challenges, specifically a disconnect and disbalance in incentive levels between service provision and service quality indicators; implementation challenges including payment delays, issues around performance verification, and insufficient implementation of activities to strengthen stock management skills; and concurrently implemented policies, most importantly a national user fee exemption for children and pregnant women half way through the impact evaluation period. The case of PBF and EM availability in Burkina Faso illustrates the difficulty of incentivizing and effecting holistic change in EM availability in the presence of strong contextual constraints and powerful concurrent policies.