UWCScholar :: Browsing by Author "Laing, Richard"

Browsing by Author "Laing, Richard"

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Analyzing implementation dynamics using theory-driven evaluation principles: lessons learnt from a South African centralized chronic dispensing model
(BioMed Central, 2017) Magadzire, Bvudzai Priscilla; Marchal, Bruno; Mathys, Tania; Laing, Richard; Ward, Kim
BACKGROUND: Centralized dispensing of essential medicines is one of South Africa’s strategies to address the shortage of pharmacists, reduce patients’ waiting times and reduce over-crowding at public sector healthcare facilities. This article reports findings of an evaluation of the Chronic Dispensing Unit (CDU) in one province. The objectives of this process evaluation were to: (1) compare what was planned versus the actual implementation and (2) establish the causal elements and contextual factors influencing implementation. METHODS: This qualitative study employed key informant interviews with the intervention’s implementers (clinicians, managers and the service provider) [N = 40], and a review of policy and program documents. Data were thematically analyzed by identifying the main influences shaping the implementation process. Theory-driven evaluation principles were applied as a theoretical framework to explain implementation dynamics. RESULTS: The overall participants’ response about the CDU was positive and the majority of informants concurred that the establishment of the CDU to dispense large volumes of medicines is a beneficial strategy to address healthcare barriers because mechanical functions are automated and distribution of medicines much quicker. However, implementation was influenced by the context and discrepancies between planned activities and actual implementation were noted. Procurement inefficiencies at central level caused medicine stock-outs and affected CDU activities. At the frontline, actors were aware of the CDU’s implementation guidelines regarding patient selection, prescription validity and management of non-collected medicines but these were adapted to accommodate practical realities and to meet performance targets attached to the intervention. Implementation success was a result of a combination of ‘hardware’ (e.g. training, policies, implementation support and appropriate infrastructure) and ‘software’ (e.g. ownership, cooperation between healthcare practitioners and trust) factors. CONCLUSION: This study shows that health system interventions have unpredictable paths of implementation. Discrepancies between planned and actual implementation reinforce findings in existing literature suggesting that while tools and defined operating procedures are necessary for any intervention, their successful application depends crucially on the context and environment in which implementation occurs. We anticipate that this evaluation will stimulate wider thinking about the implementation of similar models in low- and middle-income countries.
Baseline assessment of WHO's target for both availability and affordability of essential medicines to treat non-communicable diseases
(Public Library of Science, 2017) Ewen, Margaret; Zweekhorst, Marjolein; Regeer, Barbara; Laing, Richard
BACKGROUND: WHO has set a voluntary target of 80% availability of affordable essential medicines, including generics, to treat major non-communicable diseases (NCDs), in the public and private sectors of countries by 2025. We undertook a secondary analysis of data from 30 surveys in low- and middle-income countries, conducted from 2008±2015 using the World Health Organization (WHO)/Health Action International (HAI) medicine availability and price survey methodology, to establish a baseline for this target. METHODS: Data for 49 medicines (lowest priced generics and originator brands) to treat cardiovascular diseases (CVD), diabetes, chronic obstructive pulmonary diseases (COPD) and central nervous system (CNS) conditions were analysed to determine their availability in healthcare facilities and pharmacies, their affordability for those on low incomes (based on median patient prices of each medicine), and the percentage of medicines that were both available and affordable. Affordability was expressed as the number of days' wages of the lowestpaid unskilled government worker needed to purchase 30 days' supply using standard treatment regimens. Paying more than 1 days' wages was considered unaffordable. FINDINGS: In low-income countries, 15.2% and 18.9% of lowest-priced generics met WHO's target in the public and private sectors, respectively, and 2.6% and 5.2% of originator brands. In lower-middle income countries, 23.8% and 23.2% of lowest priced generics, and 0.8% and 1.4% of originator brands, met the target in the public and private sectors, respectively. In upper-middle income countries, the situation was better for generics but still suboptimal as 36.0% and 39.4% met the target in public and private sectors, respectively. For originator brands in upper-middle income countries, none reached the target in the public sector and 13.7% in the private sector. Across the therapeutic groups for lowest priced generics, CVD medicines in low-income countries (11.9%), and CNS medicines in lower-middle (10.2%) and upper-middle income countries (33.3%), were least available and affordable in the public sector. In the private sector for lowest priced generics, CNS medicines were least available and affordable in all three country income groups (11.4%, 5.8% and 29.3% in low-, lower-middle and upper-middle income countries respectively). INTERPRETATION: This data, which can act as a baseline for the WHO target, shows low availability and/or poor affordability is resulting in few essential NCD medicines meeting the target in low- and middle-income countries. In the era of Sustainable Development Goals, and as countries work to achieve Universal Health Coverage, increased commitments are needed by governments to improve the situation through the development of evidence-informed, nationallycontextualised interventions, with regular monitoring of NCD medicine availability, patient prices and affordability.
Baseline assessment of WHO's target for both availability and affordability of essential medicines to treat non-communicable diseases
(Public Library of Science, 2017) Ewen, Margaret; Zweekhorst, Marjolein; Regeer, Barbara; Laing, Richard
Background: WHO has set a voluntary target of 80% availability of affordable essential medicines, including generics, to treat major non-communicable diseases (NCDs), in the public and private sectors of countries by 2025. We undertook a secondary analysis of data from 30 surveys in low- and middle-income countries, conducted from 2008-2015 using the World Health Organization (WHO)/Health Action International (HAI) medicine availability and price survey methodology, to establish a baseline for this target. Methods Data for 49 medicines (lowest priced generics and originator brands) to treat cardiovascular diseases (CVD), diabetes, chronic obstructive pulmonary diseases (COPD) and central nervous system (CNS) conditions were analysed to determine their availability in healthcare facilities and pharmacies, their affordability for those on low incomes (based on median patient prices of each medicine), and the percentage of medicines that were both available and affordable. Affordability was expressed as the number of days' wages of the lowestpaid unskilled government worker needed to purchase 30 days' supply using standard treatment regimens. Paying more than 1 days' wages was considered unaffordable. Findings In low-income countries, 15.2% and 18.9% of lowest-priced generics met WHO's target in the public and private sectors, respectively, and 2.6% and 5.2% of originator brands. In lower-middle income countries, 23.8% and 23.2% of lowest priced generics, and 0.8% and 1.4% of originator brands, met the target in the public and private sectors, respectively. In upper-middle income countries, the situation was better for generics but still suboptimal as 36.0% and 39.4% met the target in public and private sectors, respectively. For originator brands in upper-middle income countries, none reached the target in the public sector and 13.7% in the private sector. Across the therapeutic groups for lowest priced generics, CVD medicines in low-income countries (11.9%), and CNS medicines in lower-middle (10.2%) and upper-middle income countries (33.3%), were least available and affordable in the public sector. In the private sector for lowest priced generics, CNS medicines were least available and affordable in all three country income groups (11.4%, 5.8% and 29.3% in low-, lower-middle and upper-middle income countries respectively). Interpretation This data, which can act as a baseline for the WHO target, shows low availability and/or poor affordability is resulting in few essential NCD medicines meeting the target in low- and middle-income countries. In the era of Sustainable Development Goals, and as countries work to achieve Universal Health Coverage, increased commitments are needed by governments to improve the situation through the development of evidence-informed, nationallycontextualised interventions, with regular monitoring of NCD medicine availability, patient prices and affordability.
Comparative analysis of essential medicines for cardiovascular diseases in countries of the WHO Eastern Mediterranean Region
(World Health Organization, 2018) Mehrtash, Hedieh; Laing, Richard; Wirtz, Veronika J.
Adequate access to essential medicines for cardiovascular disease is necessary to address the high cardiovascular disease burden in countries of the Eastern Mediterranean Region of the World Health Organization (WHO). This study compared the cardiovascular disease medicines included in the WHO Model Essential Medicines List with those in the national essential medicines lists of 19 countries of the Region. Data were extracted on the number of cardiovascular medicines and dosage forms in the national lists and compared with those on the WHO Model List (24 medicines in total and 48 dosage forms). Factors associated with the number of essential cardiovascular medicines on the national lists (burden of cardiovascular diseases and health expenditure per capita) were assessed. The number of medicines from 6 therapeutic groups of cardiovascular medicines listed in the national lists but not in the core WHO Model List were evaluated.
Household access to non-communicable disease medicines during universal health care roll-out in Kenya: A time series analysis
(Public Library of Science, 2022) Kiragu, Zana Wangari; Rockers, Peter C.; Laing, Richard
This study aims to describe trends and estimate impact of county-level universal health coverage expansion in Kenya on household availability of non-communicable disease medicines, medicine obtainment at public hospitals and proportion of medicines obtained free of charge. Data from phone surveillance of households in eight Kenyan counties between December 2016 and September 2019 were used. Three primary outcomes related to access were assessed based on patient report: availability of non-communicable disease medicines at the household; non-communicable disease medicine obtainment at a public hospital versus a different outlet; and non-communicable disease medicine obtainment free of cost versus at a non-zero price. Mixed models adjusting for fixed and random effects were used to estimate associations between outcomes of interest and UHC exposure.
Management of type 1 diabetes in low- and middle- income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania
(Wiley, 2022) Abdraimova, Aida; Besançon, Stéphane; Laing, Richard
To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania. The Rapid Assessment Protocol for Insulin Access, a multi- level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin. Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes- related supplies, this has not necessarily translated into access to insulin or diabetes care for all.
Perceptions of Kenyan adults on access to medicines for non-communicable diseases: A qualitative study
(Public Library of Science, 2018) Onyango, Monica Adhiambo; Vian, Taryn; Hirsch, Isabel; Salvi, Devashri D.; Laing, Richard; Rockers, Peter C.; Ashigbie, Paul G.; Wirtz, Veronika J.
In Kenya, noncommunicable diseases (NCDs) account for 27% of all deaths. Adult Kenyans have an 18% chance of dying prematurely from cancers, diabetes, cardiovascular diseases or chronic respiratory diseases. A Novartis Access Initiative is making medicines available to treat cardiovascular diseases, diabetes, chronic respiratory diseases, and breast cancer in 30 countries, including Kenya. Little is known about patients' perceptions of access to medicines for NCDs in Kenya. The study objective was to understand patients' perceptions of access to medicines; as well as barriers and facilitators at the household, community, and healthcare system level. A baseline qualitative study was conducted in eight of 47 counties as part of an evaluation of the Novartis Access Initiative in Kenya. The 84 patients interviewed through a household survey had been diagnosed and treated for an NCD. Although medicines at government facilities were free or cheaper than those sold in private pharmacies, the availability of medicines presented a constant challenge. Patients often resorted to private pharmacies, where NCD medicines cost more than at public facilities. Participants with an NCD took their health seriously and strove to get the medicines, even under difficult circumstances. Buying NCD medicines put a strain on the household budget, especially for the lower-income participants. Some actions to overcome affordability barriers included: borrowing money, selling assets, seeking help from relatives, taking on extra work, buying partial dosages, leaving without the medicines, or resorting to non-medical alternatives. In conclusion, access to NCD medicines is a major challenge for most adults in Kenya. As a result, they engage in complex interactions between public, private facilities and pharmacies to overcome the barriers. The government should ensure well-stocked public sector pharmacies and subsidize prices of medicines for lower-income patients. Integration of industryled access to medicine programs may help governments to obtain low cost supplies.
Prices and availability of locally produced and imported medicines in Ethiopia and Tanzania
(BioMed Central Ltd., 2017) Ewen, Margaret; Kaplan, W.; Gedif, T.; Justin-Temu, M.; Vialle-Valentin, C.; Mirza, Z.; Regeer, Barbara; Zweekhorst, M.; Laing, Richard
Background: To assess the effect of policies supporting local medicine production to improve access to medicines. Methods: We adapted the WHO/HAI instruments measuring medicines availability and prices to differentiate local from imported products, then pilot tested in Ethiopia and Tanzania. In each outlet, prices were recorded for all products in stock for medicines on a country-specific list. Government procurement prices were also collected. Prices were compared to an international reference and expressed as median price ratios (MPR). Results: The Ethiopian government paid more for local products (median MPR = 1.20) than for imports (median MPR = 0.84). Eight of nine medicines procured as both local and imported products were cheaper when imported. Availability was better for local products compared to imports, in the public (48% vs. 19%, respectively) and private (54% vs. 35%, respectively) sectors. Patient prices were lower for imports in the public sector (median MPR = 1.18[imported] vs. 1.44[local]) and higher in the private sector (median MPR = 5.42[imported] vs. 1.85[local]). In the public sector, patients paid 17% and 53% more than the government procurement price for local and imported products, respectively. The Tanzanian government paid less for local products (median MPR = 0.69) than imports (median MPR = 1.34). In the public sector, availability of local and imported products was 21% and 32% respectively, with patients paying slightly more for local products (median MPR = 1.35[imported] vs. 1.44[local]). In the private sector, local products were less available (21%) than imports (70%) but prices were similar (median MPR = 2.29[imported] vs. 2.27[local]). In the public sector, patients paid 135% and 65% more than the government procurement price for local and imported products, respectively. Conclusions: Our results show how local production can affect availability and prices, and how it can be influenced by preferential purchasing and mark-ups in the public sector. Governments need to evaluate the impact of local production policies, and adjust policies to protect patients from paying more for local products.
Probability and amount of medicines expenditure according to health insurance status in Kenya: A household survey in eight counties
(Wiley, 2021) Wirtz, Veronika J.; Servan-Mori, Edson; Laing, Richard
National and county governments in Kenya have introduced various health insurance schemes to protect households against financial hardship as a result of large health expenditure. This study examines the relationship between health insurance and medicine expenditure in eight counties in Kenya.A cross-sectional study of collected primary data via household survey in eight counties was performed. Three measures of medicine expenditure were analysed: the probability of any out-of-pocket expenditure (OOPE) on medicines in the last 4 weeks; amount of OOPE on medicines; and OOPE on medicines as a proportion of total OOPE on health.
Program sustainability post PEPFAR direct service support in the Western Cape, South Africa
(Public Library of Science, 2021) Chiliza, Jessica; Laing, Richard; Feeley III, Frank Goodrich
Public health practitioners have little guidance around how to plan for the sustainability of donor sponsored programs after the donor withdraws. The literature is broad and provides no consensus on a definition of sustainability. This study used a mixed-methods methodology to assess program sustainability factors to inform donor-funded programs.This study examined 61 health facilities in the Western Cape, South Africa, supported by four PEPFAR-funded non-governmental organizations from 2007 to 2012. Retention in care (RIC) was used to determine health facility performance. Sustainability was measured by comparing RIC during PEPFAR direct service (20072012), to RIC in the post PEPFAR period (2013 to 2015). Forty-three semi-structured in-depth interviews were conducted with key informants. The qualitative data were used to examine how predictor variables were operationalized at a health facility and NGO level.
Reasons why insured consumers co-pay for medicines at retail pharmacies in Pretoria, South Africa
(AOSIS, 2019) Mpanza, Ntobeko M.; Bradley, Hazel; Laing, Richard
Costly prescription medicines with existing cheaper alternatives tend to be purchased by medically insured consumers of healthcare. In South Africa medical scheme members pay higher out-of-pocket payments for medicines than those without insurance.This study explored reasons for co-payments among insured Pretoria medical scheme members purchasing prescription medicines at private retail pharmacies, despite being insured and protected against such payments.
Study protocol for a cluster-randomised controlled trial of an NCD access to medicines initiative: evaluation of Novartis Access in Kenya
(BMJ Publishing Group, 2016) Rockers, Peter C.; Wirtz, Veronika J.; Vian, Taryn; Onyango, Monica A.; Ashigbie, Paul G.; Laing, Richard
INTRODUCTION: Novartis recently launched Novartis Access, an initiative to provide a basket of reduced price medicines for non-communicable diseases (NCDs) to be sold through the public and private nonprofit sectors in programme countries. This study will evaluate the impact of Novartis Access on the availability and price of NCD medicines at health facilities and households in Kenya, the first country to receive the programme. METHODS AND ANALYSIS: This study will be a clusterrandomised controlled trial. 8 counties in Kenya will be randomly assigned to the intervention or control group using a covariate constrained randomisation method to maximise balance on demographic and health characteristics. In intervention counties, public and private non-profit health facilities will be able to order Novartis Access NCD medicines from the Mission for Essential Drugs and Supplies (MEDS). Data will be collected from a random sample of 384 health facilities and 800 households at baseline, midline after 1-year of intervention, and end-line after 2 years. Quarterly surveillance data will also be collected from health facilities and a subsample of households through phone-based interviews. Households will be eligible if at least one resident has been previously diagnosed and prescribed a medicine for an NCD addressed by Novartis Access, including hypertension and diabetes. The primary outcomes will be availability and price of NCD medicines at health facilities, and availability, price, and expenditures on NCD medicines at households. Impacts will be estimated using intentionto- treat analysis. ETHICS AND DISSEMINATION: This protocol was approved by the Institutional Review Boards at Strathmore University and at Boston University. Informed consent will be obtained from all participants at the start of the trial. The findings of the trial will be disseminated through peer-reviewed journals, international conferences, and meetings and events organised with local stakeholders.
The survival of patients enrolled in a global direct-to-patient cancer medicine donation program: The Glivec International Patient Assistance Program (GIPAP)
(Elsevier, 2020) Laing, Richard; Umeh, Chukwuemeka Anthony; Garcia-Gonzalez, Pat
The Glivec International Patient Assistance Program (GIPAP) is a unique direct-to-patient program that provides imatinib (Glivec) at no cost to eligible patients in low- and middle-income countries (LMICs) with chronic myelogenous leukemia (CML) or gastrointestinal stromal tumor (GIST). This paper analyses the output, outcome and impact of the program between 2001 and 2014 using the data collected by the Max Foundation. Method: We extracted data on GIPAP patients’ country of residence, sex, diagnosis, date of enrollment in GIPAP, age at enrollment, case closure date, and reason for closure from The Max Foundation database covering the period 2001 to 2014. We used Kaplan-Meier method to assess the survival rate of patients in GIPAP and used the proportional hazard regression model to estimate the effect of different variables on patients’ survival. Findings: About 63,000 GIPAP patients in 93 countries received over 71 million defined daily doses (DDD) of imatinib between 2001 and 2014. Our analysis showed that GIPAP patients had a 5-year survival rate of 89% which compares favorably to survival in high income countries despite the challenges of delivering cancer care in LMICs. Age at enrollment into the program, sex, duration between diagnosis and enrollment into program, year of enrollment, and patients’ diagnosis (CML vs non-CML) were factors that influenced survival.
A systematic approach to improve rational medicine use in Eswatini
(University of Western Cape, 2020) Ncube, Nondumiso Beauty Queeneth; Bradley, Hazel Anne; Schneider, Helen; Laing, Richard
Studies on rational medicine use (RMU) have mainly focused on identifying, quantifying, and addressing irrational use without exploring reasons behind this irrational use. In addition, minimal work has been conducted on irrational use of medicines in the context of the growing burden of non-communicable diseases (NCDs). This PhD research examined medicine use in Eswatini, (previously Swaziland) between April 2017 and March 2019, with a focus on prescribing practices linked to specific diagnoses. It further explored factors influencing RMU, which included testing the effects of a short intervention - prescription audit and feedback coupled with small group education - on prescribing practices in health facilities.

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