PHCPI Data Insight: Drug availability an essential component of effective primary health care systems
Diarrhea is a leading cause of death in children under five, especially in the sub-Saharan Africa region. As diarrhea can be easily treated with oral rehydration and continued feeding, the percent of children with diarrhea receiving treatment is an important indicator of primary health care (PHC) performance in low and middle-income countries (LMICs).
PHCPI uses children with diarrhea receiving appropriate treatment—the percent of children with diarrhea who received appropriate treatment with oral rehydration and continued feeding—as a widely available indicator for effective service coverage. This indicator reflects trust in the primary health care system, financial and geographical access to treatment, and health knowledge and behaviors of providers and patients. In order for providers and parents to administer appropriate treatment to children suffering from diarrhea, the essential medicines must be available in the first place. Essential drug availability, a PHCPI indicator, measures “the number of unexpired drugs in a health facility compared to the total expected number of drugs on the list defined by the World Health Organization." Because oral rehydration salts (ORS) are included on the WHO list of essential medicines for children, looking at the relationship between essential drug availability and children with diarrhea receiving appropriate treatment can help us identify which countries successfully convert the input of ORS availability into effective care, so that other countries can learn from these successes.
The PHCPI compare tool allows us to make this comparison and visualize how key aspects of service delivery are performing within and across primary health care systems. This analysis shows that there are two main categories of countries: those with an expected relationship (low drug availability and a low percentage of children receiving treatment, or high drug availability and high percentage of children receiving treatment), and those countries in which this expected correlation is not seen—that is, high drug availability does not translate to high percentage of children receiving treatment, or an unexpectedly high percentage of children receive treatment despite low reported drug availability.
What do these indicators tell us?
For countries such as Tanzania and Zambia, in which there is both high essential drug availability and a high percentage of children with diarrhea who receive treatment, the systems have been able to convert their high drug availability to effective coverage of diarrhea treatment. Such a relationship could indicate not just a well-functioning supply chain, but better service delivery capacity resulting in quality case management in the PHC system.
For countries such as Burkina Faso, Mauritania, Uganda, and Togo, in which there is both low essential drug availability and a low percentage of children with diarrhea receiving treatment, one of the reasons likely contributing to why children do not receive treatment is that ORS is not available. While supply chain issues would be an area for further analysis, it is important to recognize that there may be other factors such as lack of access to care, lack of trust in the delivery systems, or lack of knowledge of when to access treatment, which can also threaten health system performance.
Case focus: Kenya and Sierra Leone
The data available for Kenya and Sierra Leone present interesting, contrasting cases.
Prior to the Ebola outbreak, Sierra Leone had the third-highest percentage of children with diarrhea receiving treatment in the sub-Saharan Africa region, but Sierra Leone was tied with Mauritania for the lowest availability of essential drugs in the region. How could so many children be receiving treatment when essential medicine availability was so low? Because ORS is only one of many drugs on the WHO essential drug list, it is possible that, while other essential drugs are lacking, ORS was in fact widely available, representing a partially functional supply chain (especially for low cost medicines like ORS). In this case, in the wake of devastating civil war in Sierra Leone, donor-driven vertical programs focused specifically on ORS, which improved supply-chains, increased tracking of distribution, and increased community-based ORS promotion. This concentrated, narrow focus on improving ORS availability may explain why coverage of appropriate diarrhea treatment is higher than might be anticipated from the supply chain indicator. While it is clear that vertical programs like this can have strong, positive impacts on certain outcomes, the persistent shortages of other essential drugs and available health workers in Sierra Leone—as well as the country’s high under-five mortality rate—underscore the necessity of a stronger primary health care system that can comprehensively address patient needs in a coordinated and continuous manner.
In contrast to Sierra Leone, Kenya has a relatively high drug availability yet still a relatively low percentage of children with diarrhea who receive the appropriate treatment compared to other LMICs. What are the possible explanations for this disconnect between drug availability and case treatment? Since drug availability is likely not the only factor, this gap could indicate challenges in other domains including access to care (geographic, financial, etc.) or a lack of trust or health knowledge and health-promoting behaviors on the part of patients. For example, this observation could suggest that treatment is not sought out for children with diarrhea, that proper management of dehydration cases is not occurring, that communities rely on home-produced or traditional medicines, or that caregivers do not properly follow prescribed treatment.
The Kenya and Sierra Leone examples demonstrate that primary health care inputs, like essential drugs, do not automatically get converted to effective service coverage, and that a focus on vertical programming is inadequate to improve the health outcomes that we ultimately care about, including child mortality. A deeper understanding of the linkages across the PHCPI framework will help countries understand when inputs are effectively translated through service delivery into effective coverage, and where additional work is needed to ensure comprehensive, continuous, and people-centered care.
Hannah Ratcliffe is a Research Analyst at Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T. H Chan School of Public Health.
Elisabeth Tadiri is a Primary Health Care Intern at Ariadne Labs, , a joint center between Brigham and Women’s Hospital and the Harvard T. H Chan School of Public Health.
Photo credit: Health Communication Capacity Collaboration