NCD Medicines and Products — Not Just Resource Limited, But Resource Variable
Blog #4 in the Coalition for Access to NCD Medicines and Products blog series.
World bank classifications of country income levels are widely used to infer the resources available in health systems around the world. Based on these classifications, people often refer to settings like Uganda, or other countries where the Coalition for Access to NCD Medicines and Products is active, as low-resource, low-income, or resource-constrained. Yet this framing implies that resources are static and homogeneous, overlooking a key characteristic of these settings: variation in resources, both within the setting and over time. Consistency in resources such as medicines and equipment over time is crucial for effective care of chronic conditions because these conditions progress over time and must be treated for long periods, if not indefinitely.
Health resources can vary substantially within countries and even within health facilities. Many factors contribute to this variation. These include national or local policy, budgeting and financing cycles, allocation of funds at the governmental, jurisdiction, and/or clinic level, supply chain interruptions, among others. As a result, within the same health facility, an HIV clinic may be well-stocked and staffed while an NCD clinic lacks basic equipment or trained staff. Basic medical equipment may be available in the capital city region, but rarely available outside it. Medicines and procedures may be immediately available to paying patients at private clinics but rarely available to patients of lower cost public-sector facilities. Perhaps most importantly, availability of key health resources like medicines, serviceable equipment, and basic materials for people to manage their disease (i.e. insulin syringes, glucometer test strips, etc) can vary over even short periods of time.
“There are times when we spend about two to three months without receiving medicines. Like by the end of last month, we had spent two months without receiving medicines.” — a person living with NCDs in Uganda
“What brings more problems is when the test strips are out of stock, yet it is a must we have to take the blood test before we get medicines and the doctor will not work on you before your blood is checked.” — a person living with NCDs describing the challenges of variability in supplies
Health care systems should be assessed both by the resource limitations they face and by the extent of resource variability they experience. Resource variability — which we define as the degree of dynamism in resources over time or space — is distinct from resource level. In the example depicted in the Figure, we present four hypothetical health systems using availability of metformin, a commonly prescribed medicine for diabetes, as an example. The first (blue box), a high-resource system with low variability, has high health commodity security- it offers its users certainty that resources present one week will continue to be present the next week. The second (green box), is also a high resource system but one that has high variability: the availability and/or cost-to-patient of resources such as medicines fluctuates over time and varies from location to location. For example, a country like the United States would commonly be characterized as high-resource, yet it is also characterized by a high degree of variation in resources, with vast disparities in access to affordable medicines and care. The COVID pandemic has thrust the fragility of health care supply chains into the public eye and exposed the importance of variability for resources such as personal protective equipment and reagents for laboratory testing — even in the highest-resource nations. The third (red box), is a low resource system with low variability. For example, the health system of a middle- or lower-middle-income setting like Rwanda may have lower mean resources, but the distribution of these resources might be more even and produce more certainty for patients and providers. Finally, the fourth (yellow box), is a low resource system with high variability. Given our work to date, we would characterize Uganda as an example of this type of health care system.
Using a resource variability framework can generate new insights into access to NCD medicines and products. Measuring and analyzing variation in the availability and cost of medicines and products is important because both availability and cost are dynamic in ways that directly affect patient access. We have recently shown in a pilot study in Uganda, that both availability and cost of medicines vary on a weekly basis. Some weeks, metformin is available to patients. Other weeks, at the same health facility pharmacy, it is not. This variation was much more pronounced for NCD medicines than for medicines for acute conditions such as malaria or pneumonia. It is not so much that medicines are universally available or unavailable at these health facilities as that they are inconsistently available- their availability is variable. Even at facilities where the availability of medicines is more consistent — namely private clinics — the price of those medicines can vary considerably from week to week. In our analysis, we found that more than half of the essential medicines for NCDs stocked by private clinics in central Uganda doubled in price at least once over a five-week period. Pervasive uncertainty about whether medicines will be affordable or even available from week to week could impede habit formation, threaten adherence, and reduce patients’ sense of control over their condition. This is a real risk for those with chronic conditions for which medicines need to be taken regularly over a long period of time, as opposed to short-term treatments of acute conditions.
Variation in resources over time also shapes the behavior of clinicians, who must cope with uncertain availability of key medicines, materials, and equipment. Knowing that key resources cannot be counted on to remain available may lead providers to alter their practice, catering to this variability. In another ongoing analysis, we have found that some providers hesitate to prescribe tuberculosis preventive therapy to people living with HIV in Uganda in accordance with national guidelines, even when the necessary drugs are in stock. In interviews, providers say that they worry that the drugs will go out of stock during the course of treatment. These anticipated stockouts also lead pharmacists to ration what they dispense to patients. In a previous study in Uganda, we showed that 57% of prescribed medicine doses for hypertension or diabetes are not dispensed at the pharmacies where they were prescribed. The top two reasons for this prescribing-dispensing gap were stockouts and anticipated stockouts.
“But even now our hands are tied! Most of these medicines [for complications] are never stocked. It is also difficult to obtain some of them from the open market. That is why we try to restrict ourselves by prescribing what is available unless the condition is worse”. — a provider describing the challenges of medicine availability variability.
Resources may vary not only over time, but between locations within the same country. Also in Uganda, we have previously shown that availability of essential medicines varies significantly by the region in which a health facility is located, whether it is public, private, or not-for-profit, and whether it is a clinic or hospital. We also observe that resource microenvironments exist. For example, within the same health center or hospital, medicine availability will vary. There might be high variability in availability of NCD medicines (“non-fully-supply commodities”) but low variability of antiretrovirals used to treat HIV (“full-supply commodities”). The causes of such resource microenvironments are multifactorial; they may arise due to financial prioritization by system stakeholders, leadership, or even the quality of record keeping and data monitoring that impede or promote accurate demand forecasting of medicines.
Beyond the need to measure variation in the availability and cost of medicines and products, the definition of ‘resources’ should be expanded to include other household and patient-level factors. Managing chronic conditions requires significant patient-level resources: tangible resources like income and time, but also psychosocial or ‘psycho-emotional’ resources such as empowerment, autonomy, self-determination, self-efficacy, and health locus of control. These, too, are not static and inherent, but responsive to the broader environment. Moreover, visiting four or five different private pharmacies to find the medications you need and eventually paying out-of-pocket for something that should be government provided could feasibly erode several of these patient-level resources. Conversely, knowing that you are able to receive consistent care, that medications will always be in stock, and within your financial means may significantly increase self-efficacy and empowerment and lead to better physiological outcomes. Variability in these patient-level resources may be, in part, buffered by household-level resources (social and economic) but are likely to be key mediators of the impact of variability in availability and cost of medicines and other products on clinical outcomes.
To expand our understanding of resource variability, and to examine it at multiple levels — system, household, and individual — we need to embark upon ambitious, longitudinal research studies, especially in low- and middle-income countries. Such studies will also foster more in-depth analysis into the varied determinants of variability. In the meantime, solutions such as the development of an innovative demand forecasting tool for consolidating and analyzing available data and quantifying needs for NCD products, by the Coalition for Access to NCD Medicines and Products, will help to improve supply security for NCD medicines. Additionally, and importantly, such efforts will make supply chain data more transparent, visible, accurate, and, therefore, actionable. Taken together, we hope this new knowledge will spur additional innovative solutions that will both drive policy and lead to the development of evidence-informed interventions to improve chronic care delivery for vulnerable populations.
The Coalition for Access to NCD Medicines and Products is committed to working together through our activities and partnerships at the global, regional, and national levels, to build back better and improve the lives of people living with NCDs. To learn more about the Coalition, to join us in this important work, or to tell us about the work that you are doing to improve global access to NCD medicines and products, click here.
About the Authors:
Jeremy Schwartz, MD is an Associate Professor of General Internal Medicine at Yale School of Medicine and of Chronic Disease Epidemiology at Yale School of Public Health. He is also a member of the Coalition’s Technical Advisory Committee and the Demand Forecast Tool Technical Working Group.
Robert Kalyesubula, MMed is Chair of the Department of Physiology at Makerere University College of Health Sciences and Founder and President of the African Community Centre for Social Sustainability.
Mari Armstrong-Hough, PhD is an Assistant Professor in the Department of Social and Behavioral Sciences and in the Department of Epidemiology at New York University School of Global Public Health.
Nicola Hawley, PhD is an Associate Professor of Chronic Disease Epidemiology at Yale School of Public Health.
Drs. Schwartz and Hawley are founding members of the Yale Network for Global Non-Communicable Diseases.