Perceptions from pharmaceutical stakeholders on how the pharmaceutical budget is allocated in South Africa

Abstract

Background South Africa faces a heavy burden of disease, which impacts resource allocation. The needs of South Africa require efficient translation into pharmaceutical expenditure for medicine provision, to ensure availability of medicines. Given that South Africa faces various challenges with medicine provision accompanied by rising pharmaceutical expenditure, this study aimed to report on the considerations and methods used to determine the healthcare budget for South Africa, and how it is translated into pharmaceutical expenditure for medicines provision on the Standard Treatment Guidelines and Essential Medicines List and non-essential medicines in the public sector. Method Qualitative, semi-structured interviews guided by a discussion guide were conducted with seven pharmaceutical officials involved in the budget and resource allocation process, between October 2019 and March 2020. Interviews were recorded and transcribed verbatim. Once the interviews were coded by the first author they were verified by the other authors. Data were thematically analysed. Results This study depicted the knowledge and participation of pharmaceutical services in the budget process. The National and Provincial Department of Health have improved pharmaceutical budgeting by making strides towards a collaborative, informed, and more evidence-based approach. Pharmaceutical services have roles in advising on requirements; commenting where necessary, constantly monitor and taking accountability for their budget. The main considerations that determined the budget included population size and growth, historical expenditure, the extra heavy burden of disease and incidence rate, demand data and forecasting. The local and provincial pharmacy and therapeutics committee play a vital role in monitoring the budget and expenditure; ensuring adherence to guidelines; controlling the extent to which non-Essential Medicine List items are used and advising accordingly. Conclusion This was the first study to report on the decision and thought processes of the healthcare budget and its translation into pharmaceutical expenditure for medicine provision in South Africa. Many factors were considered to inform the budget, with the Standard Treatment Guideline and Essential Medicines List being the principal guide for medicine provision. This process was well-controlled and monitored by the pharmaceutical therapeutics committee. Documenting the South African experience can assist other countries in their budget decisions for medicines.

National adaptation and implementation of WHO Model List of Essential Medicines: A qualitative evidence synthesis

“…Nsabagasani and colleagues studied how Uganda responded to the 2012 WHO recommendations on child-appropriate dosage formulations and identified weak institutional capacity in convening relevant stakeholders to assess how the country could move forward in adopting the recommendations [ 39 ]. In addition, technical advisory committees could have a wider mandate or longer-term role [ 16 , 18 , 41 ], with a study from Ghana suggesting the committees could have a role in advocating for greater adherence to NMLs [ 18 ]. To improve implementation, more attention to adherence and compliance strategies could be achieved through better coordination and oversight by scientific selection committees.…”

“…Enforcement strategies and policy controls from health authorities are crucial factors affecting the prescribing and availability of medicines prioritized by NMLs [ 16 , 20 , 42 , 43 ]. Key factors preventing effective implementation can be the lack of an enforceable regulatory or legislative framework supporting compliance to NMLs, including linkages to pharmaceutical services departments [ 41 ]. Odoch and colleagues found that domestic health changes such as the devolution of health services had influenced NML updates [ 16 ].…”

“…Implementation can be particularly challenging in decentralized health systems that enable autonomy for medicine selection and use within regions and hospitals, even when a national framework for essential medicines is in place [ 5 , 20 , 44 ]. Several studies described inconsistencies between NMLs and how they are implemented at a regional or hospital level at the discretion of local doctors [ 5 , 41 , 42 , 44 ]. The lack of oversight of monitoring and implementation of NMLs resulted in hospitals diverging from national recommendations and making their own decisions related to medicine selection provision.…”

“…They identified that on occasions, it was necessary for clinicians to prescribe nonformulary mechanisms and defer to hospital management for the decision if nonformulary medicines were perceived to be too expensive [ 5 ]. At a service delivery level, the balance of medicines selected and ensuring access to those medicines prescribed can be a particular challenge [ 22 , 40 , 41 , 45 ]. Experiences from different countries underscored how the lack of implementation guidance, including monitoring and evaluation, at a subnational level can lead to unregulated adaptation or disregard for NMLs by local policymakers or prescribers [ 20 , 22 ].…”

“…These are intended to offer guidance on standardized treatment protocols and influence clinical behavior by guiding the prescribing of medicines. A finding that was assessed to have moderate to high confidence from the CERQual assessment ( Table 2 ) indicated that STGs to a varied extent facilitate implementation of a country’s NML [ 5 , 9 , 16 , 20 , 22 , 39 , 41 , 44 ]. A study from Trinidad and Tobago highlighted the value of national treatment protocols to harmonize the use of cancer medicines for adults that had been added to the essential medicines list and proposed that such an approach could also be applied to children’s cancer medicines.…”