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Yao JS, Kibu OD, Asahngwa C, Ngo NV, Ngwa W, Jasmin HM, Gobina RM, Foretia DA. A scoping review on the availability and utilization of essential opioid analgesics in Sub-Saharan Africa. Am J Surg 2023; 226:409-421. [PMID: 37024407 DOI: 10.1016/j.amjsurg.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND Management of acute, post-operative, and chronic pain requires access to and availability of opioids. While often oversupplied in high-income countries, significant shortages exist in low- and middle-income countries. We conducted a scoping review on availability and usage of opioids in Sub-Saharan Africa (SSA). METHODS The five-stage approach of Arksey and O'Malley (2005) was used. MEDLINE via PubMed, EMBASE, and SCOPUS were search and results categorized into themes: 1) Local/regional availability and supply, 2) Consumption patterns, 3) Legislation and policy, 4) Costs and financing, 5) Knowledge and cultural beliefs, and 6) Education and training. RESULTS 6923 studies were identified from which 69 (1%) met inclusion criteria. Five key findings were: 1) Significant shortages exist, especially in rural areas, 2) Non-opioid analgesics commonly used as first-line acute pain management, 3) Barriers to market entry and bureaucratic processes prevent local production, 4) Significant knowledge gaps/myths exist amongst healthcare practitioners on opioid use, and 5) Continuous education and short courses will be critical. CONCLUSIONS Major challenges significantly limit availability and utilization of essential opioids in SSA. Reforms needed to upscale training and education, increase uptake by professionals, and increase market entry.
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Affiliation(s)
- Jane S Yao
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Odette D Kibu
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Department of Public Health, University of Buea, Cameroon; Faculty of Health Science, University of Buea, Cameroon
| | - Constantine Asahngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Department of Anthropology, University of Yaoundé 1, Yaoundé, Cameroon
| | - Ngo V Ngo
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | - Wilfred Ngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | - Hilary M Jasmin
- Health Science Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ronald M Gobina
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Health Science Library, University of Tennessee Health Science Center, Memphis, TN, USA; Buea Regional Hospital, Buea, Cameroon
| | - Denis A Foretia
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Center for Multicultural and Global Health, University of Tennessee Health Science Center, Memphis, TN, USA; Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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Aregay A, O'Connor M, Stow J, Ayers N, Lee S. Perceptions of Barriers to Using Opioid Analgesics: A Mixed Methods Study. Palliat Med Rep 2023; 4:249-256. [PMID: 37771937 PMCID: PMC10523405 DOI: 10.1089/pmr.2023.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 09/30/2023] Open
Abstract
Background Availability and accessibility of opioids are a worldwide problem. In low-resource settings, such as Ethiopia, access to opioids is either limited or nonexistent and legally restricted in health care settings. This study aimed to identify barriers for the availability and accessibility of opioids in Ethiopian rural and regional health care settings. Methods A mixed-method case study design was used. A total of 220 nurses from primary, secondary, and tertiary health care settings were invited to participate in a survey of knowledge and practice. For the qualitative interview, 38 participants were recruited from educational facilities, health services, and the community across a region. Results Barriers in availability and accessibility of opioid analgesics were expressing pain considered as a sign of weakness, lack of knowledge, side effect concerns about prescribing morphine, only doctors being authorized to prescribe morphine, lack of foreign currency to import morphine ingredients, and inequity in accessing morphine in hospitals and none in rural health care settings. Conclusion The findings of this study indicate that opioids, particularly morphine, were not consistently available and accessible to all patients in need. Health professionals lacked knowledge about opioids. Strengthening the existing pain-free initiatives and improving the type, dose, and supply of morphine could help reduce needless suffering and enhance access to essential pain medicines for those in need.
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Affiliation(s)
- Atsede Aregay
- Department of Health and Nursing Sciences, University of Agder, Kristiansand, Norway
- School of Nursing, Mekelle University, Tigray, Ethiopia
| | - Margaret O'Connor
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- Department of Palliative Care, Melbourne City Mission Palliative Care, Melbourne, Victoria, Australia
| | - Jill Stow
- Department of Perioperative Medicine, St Vincent's Private Hospital, Melbourne, Victoria, Australia
| | - Nicola Ayers
- School of Nursing, BPP University, London, United Kingdom
| | - Susan Lee
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
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Ooms GI, van Oirschot J, de Kant D, van den Ham HA, Mantel-Teeuwisse AK, Reed T. Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 118:104078. [PMID: 37276779 DOI: 10.1016/j.drugpo.2023.104078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/14/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA. METHODS A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework. RESULTS The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices. CONCLUSION This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.
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Affiliation(s)
- Gaby I Ooms
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands; Health Action International, Amsterdam, the Netherlands.
| | | | | | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, the Netherlands
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Nyanchoka M, Mulaku M, Nyagol B, Owino EJ, Kariuki S, Ochodo E. Implementing essential diagnostics-learning from essential medicines: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000827. [PMID: 36962808 PMCID: PMC10121180 DOI: 10.1371/journal.pgph.0000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
The World Health Organization (WHO) model list of Essential In vitro Diagnostic (EDL) introduced in 2018 complements the established Essential Medicines List (EML) and improves its impact on advancing universal health coverage and better health outcomes. We conducted a scoping review of the literature on implementing the WHO essential lists in Africa to inform the implementation of the recently introduced EDL. We searched eight electronic databases for studies reporting on implementing the WHO EDL and EML in Africa. Two authors independently conducted study selection and data extraction, with disagreements resolved through discussion. We used the Supporting the Use of Research Evidence (SURE) framework to extract themes and synthesised findings using thematic content analysis. We used the Mixed Method Appraisal Tool (MMAT) version 2018 to assess the quality of included studies. We included 172 studies reporting on EDL and EML after screening 3,813 articles titles and abstracts and 1,545 full-text papers. Most (75%, n = 129) studies were purely quantitative in design, comprising descriptive cross-sectional designs (60%, n = 104), 15% (n = 26) were purely qualitative, and 10% (n = 17) had mixed-methods approaches. There were no qualitative or randomised experimental studies about EDL. The main barrier facing the EML and EDL was poorly equipped health facilities-including unavailability or stock-outs of essential in vitro diagnostics and medicines. Financial and non-financial incentives to health facilities and workers were key enablers in implementing the EML; however, their impact differed from one context to another. Only fifty-six (33%) of the included studies were of high quality. Poorly equipped and stocked health facilities remain an implementation barrier to essential diagnostics and medicines. Health system interventions such as financial and non-financial incentives to improve their availability can be applied in different contexts. More implementation study designs, such as experimental and qualitative studies, are required to evaluate the effectiveness of essential lists.
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Affiliation(s)
- Moriasi Nyanchoka
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mercy Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Department of Pharmacology, Clinical Pharmacy, and Pharmacy Practice, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Bruce Nyagol
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Eddy Johnson Owino
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Sabogal De La Pava ML, Tucker EL. Drug shortages in low- and middle-income countries: Colombia as a case study. J Pharm Policy Pract 2022; 15:42. [PMID: 35698240 PMCID: PMC9189796 DOI: 10.1186/s40545-022-00439-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Drug shortages are a global problem. Analyzing shortages worldwide is important to identify possible relationships between drug shortages across countries, determine strategies that reduce drug shortages, and reduce the inequality in access to medicines between countries. In contrast to well-documented shortages in high-income countries, there are few studies that consider low- and middle-income economies. We evaluate drug shortages in one middle-income country, Colombia. Methods We collected data from INVIMA, the institution responsible for managing medicine shortage alerts in Colombia. We classified the data using the Anatomical Therapeutic Chemical (ATC) classification system and analyzed them using descriptive statistics. We considered a study period from 2015 to 2021 (vital medicines) and from 2010 to 2020 (non-vital medicines). Results In total, 173 unique ATC codes were in shortage. These included antidotes, alimentary tract and metabolism products, anesthetics, cardiac stimulants and antithrombotic agents. The major causes were manufacturing problems and few suppliers. Drug shortages substantially increased from 2020 to May 2021 due to the COVID-19 pandemic. Among resolved shortages, the average duration was 1.6 years with a standard deviation of 1.9 years. The longest, naloxone tablets, were in shortage for almost 10 years. Conclusions Drug shortages are a persistent problem in Colombia. Government institutions have made progress in implementing systems and procedures to report them. However, the approaches implemented need to be maintained and refined. This study lays the groundwork for the analysis of drug shortages in other LMICs. We highlight the necessity of addressing drug shortages in their global context and reducing the inequality in access to medicines between countries.
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Affiliation(s)
| | - Emily L Tucker
- Department of Industrial Engineering, Clemson University, Clemson, SC, USA.,School of Health Research, Clemson University, Clemson, SC, USA
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Luyirika E, Lohman D, Ali Z, Atieno M, Mahenge A, Mmbando P, Muinga E, Musyoki D, Mwesiga MD, Namisango E, Nosim P, Opio G, Pardy S, Ruzima A, Skowronska E, Uhagaze B, Zalwango J, Aluso A. Progress Update: Palliative Care Development Between 2017 and 2020 in Five African Countries. J Pain Symptom Manage 2022; 63:729-736. [PMID: 34973351 DOI: 10.1016/j.jpainsymman.2021.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT This article provides a progress update on the development of palliative care in five countries in Africa-Kenya, Rwanda, South Africa, Tanzania, and Uganda-between 2017 and 2021, and explores the role of palliative care advocates and the Open Society Foundations in this process. OBJECTIVES To provide a progress update on the development of palliative care in Kenya, Rwanda, South Africa, Tanzania, and Uganda between 2017 and 2021 and to examine the impact of twenty years of Open Society Foundations support for palliative care in the region on the integration of palliative care into publicly funded health systems. METHODS In the mid-2000s, palliative care pioneers in these five countries, supported by Open Society Foundations, began to train health care providers and engage policy makers to ensure that people with life-limiting illnesses and their families had access to appropriate services and essential medicines. In the late 2010s, it embraced an approach that mixed strategic communications and advocacy for inclusion of palliative care into universal health coverage with technical assistance. RESULTS By the mid-2010s, a vibrant palliative care community existed that worked closely with governments to develop palliative care policies, train providers, and ensure access to morphine. By 2021, Kenya and Rwanda had made significant progress scaling up palliative care services as part of the public health care system, and Uganda's government had instructed public hospitals to start providing these services. In South Africa and Tanzania, governments had yet to commit to publicly funded palliative care services. CONCLUSION The experiences in these countries suggest that mixing advocacy, communications, and technical assistance can lead to substantial progress for patient access although full inclusion in universal health coverage remained uncertain in all but Rwanda.
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Affiliation(s)
| | - Diederik Lohman
- Open Society Foundations (D.L., S.P.), New York, New York, USA.
| | - Zipporah Ali
- Kenya Hospices and Palliative Care Association (Z.A., M.A., E.M., D.M.), Nairobi, Kenya
| | - Mackuline Atieno
- Kenya Hospices and Palliative Care Association (Z.A., M.A., E.M., D.M.), Nairobi, Kenya
| | - Anna Mahenge
- Evangelical Lutheran Church in Tanzania (ELCT) (A.M., P.M., P.N.), Arusha, Tanzania
| | - Paul Mmbando
- Evangelical Lutheran Church in Tanzania (ELCT) (A.M., P.M., P.N.), Arusha, Tanzania
| | - Esther Muinga
- Kenya Hospices and Palliative Care Association (Z.A., M.A., E.M., D.M.), Nairobi, Kenya
| | - David Musyoki
- Kenya Hospices and Palliative Care Association (Z.A., M.A., E.M., D.M.), Nairobi, Kenya
| | - Mark Donald Mwesiga
- Palliative Care Association of Uganda (PCAU) (M.D.M., J.Z.), Kampala, Uganda
| | - Eve Namisango
- African Palliative Care Association (E.L., E.N.), Kampala, Uganda
| | - Peter Nosim
- Evangelical Lutheran Church in Tanzania (ELCT) (A.M., P.M., P.N.), Arusha, Tanzania
| | - Geoffrey Opio
- Open Society Initiative for East Africa (G.P., A.A.), Kampala, Uganda
| | - Sara Pardy
- Open Society Foundations (D.L., S.P.), New York, New York, USA
| | - Aimable Ruzima
- Rwanda Palliative Care and Hospice Organization (A.R., B.U.), Kigali, Rwanda
| | - Eva Skowronska
- Hospice Palliative Care Association (HPCA) (E.S.), Cape Town, South Africa
| | - Blaise Uhagaze
- Rwanda Palliative Care and Hospice Organization (A.R., B.U.), Kigali, Rwanda
| | - Joyce Zalwango
- Palliative Care Association of Uganda (PCAU) (M.D.M., J.Z.), Kampala, Uganda
| | - Aggrey Aluso
- Open Society Initiative for East Africa (G.P., A.A.), Kampala, Uganda
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