Availability, long stock out durations and affordability are three major factors that affect access to medicines for most people in resource poor settings, Ghana being no exception. The results of the study clearly show these phenomena especially in public health facilities across the country. This stems from the organizational structure and procurement policies of essential medicines which are based both on the principles of decentralization and the autonomy of each facility within the drug management and distribution system (i.e. CMS»RMS» facility). Each facility is responsible for making its own procurement decisions.
The decentralized aspect of the system has both positive and negative consequences that affect rationale procurement decisions, pricing, and hence availability of medicines.
In general, MOH procurement rules state that a Regional Medical Store must look to the Central Medical Store first to source its pharmaceutical supply needs. If the CMS is unable to meet these needs, and the requested item is out of stock, then the RMS can buy from the open market. For lower level facilities, a similar approach is to be followed by going to the RMS first and then only when the RMS is unable to supply can the health facility turn to the private sector. The results obtained reflect this trend for the public sector. If the availability of medicines in the warehouse is less it affects availability at the facility level.
Another factor which affects availability and stock out duration is distance from the Central Medical Stores. Logistics especially in the area of transportation is a major hindrance to facilities which are situated very far from the CMS. This is usually noted with regions like the three northern regions including upper Upper East region which was part of the survey.
The availability at private drug outlets was better because they are profit oriented institutions and they depend solely on sales for their income and therefore cannot afford not to have the basic drugs on their premises.
Lack of funds to purchase items as they run out is faced by some facilities. The drug revolving funds which are meant solely for drugs are used for other activities that the institutions find to be equally important. In some facilities the internally generated funds from other services is not enough to run the clinics and the heads are forced to borrow funds from the pharmacy to top up for the other services. These funds are sometimes borrowed to be repaid, but most often they are not paid back into the drug revolving funds, resulting in de-capitalization of the RDF leading to non availability and stock out of certain items.
Poor inventory and financial management issues worsen the problem of availability. In certain facilities prescribing habits hinder availability of some drugs which in turn affects the stock out duration. Only certain drugs are prescribed in certain facilities depending on the prescribing habits of those prescribing in the facility resulting in the expiration of other drugs which are not "favourites" for prescription. The activities of medical representatives who promote certain medicines force some facilities to stock only the medicines which are constantly being promoted. In such a case the pharmacy will stock only those drugs which are fast moving and leave other essential drugs which are slow moving. Poor inventory and financial management could also stem from lack of skills for those in charge of the drug supply management
Affordability of medicines for the poor is a major barrier to access. It is catastrophic for an individual to use a whole days wage to pay for the treatment of pneumonia.
The results of most quality of care surveys have shown that attendance at health care facilities are affected by the inability of clients to pay for health care services.
The government of Ghana recognizes that ensuring equitable, secure and sustainable access to essential medicines is a core element of the national strategy for improving health outcomes of the population. Efforts to improve access continue to face major challenges in a rapidly changing nationa0l and international policy environment. In the pursuit of improving access to health care the Government has introduced the National Health Insurance Scheme (NHIS). A key purpose of the NHIS is to share the risk and burden of pharmaceutical and health care costs across the population and therefore, improve equity of access.
The National Health Insurance Scheme was necessitated given the increasing public concerns about the inequities inherent in the system of cost recovery known as "cash and carry". It is hoped that the National Health Insurance scheme if it is well implemented will reduce the burden of the direct out-of -pocket -at-point-of-service user payments, involved in the "Cash and Carry" system and therefore improve overall access to healthcare including access to medicines