Hrev_master [Healthcare in Low-resource Settings 2023; 11:11143] [page 53] Evidence from systematic reviews on policy approaches to improving access to medicines Celestino Kuchena,1 Abubaker Qutieshat2 1Business and Management Department, University of Zambia, Lusaka, Zambia; 2Research Department, Oman Dental College, Muscat, Oman Abstract The prevailing frameworks on access to medicines advise global procurement as a solution by assuming the presence of medi- cines on the global market. Yet access to medicines remains challenging, especially in developing countries. This is a global worry because the UN considers limited access to essential medicines as one of the five indicators of securing the right to health. To fill a research gap in health sys- tem studies and inform policymaking, we synthesized evidence from systematic reviews of how government policies affect low- and middle-income country (LMIC) medicine access. We chose a rapid review approach to reduce timelines and avoid missing policy “windows of opportunity.” To include only studies published after the start of COVID-19, we chose systematic reviews published between 2019 and November 2nd, 2022. This was also in line with recommendations in the literature to look at recent systematic reviews. The themes were grouped using a thematic and textual narrative approach. This review included 32 studies that examined access to medicine from various perspectives. Both supply- and demand-side policies are need- ed to improve medical access. LMICs can- not afford medicines, and supply never meets demand. LMICs will continue to struggle with pharmaceutical pricing due to their limited bargaining power. The urban bias in health facilities and policy changes reduce medicine availability and use. Leaders must make policy decisions to sus- tain domestic funds. Policymakers should consider that organizations may act against policy goals. Instead of copying developed nations, LMIC governments must develop multipronged strategies to address their unique challenges. Introduction There is a need for more information on how policy options affect drug access in low- and middle-income countries (LMICs).1 Researchers must evaluate how interventions affect the healthcare system.2 Grépin3 supports context-specific research, while others noted a lack of information on how policies affect universal health access.4 McPake and Hanson5 show that govern- ments must act through whole-sector poli- cies while Bigdeli et al.6 argue that the main frameworks on access to medicines thinly address how people access medicines. Research on policy and healthcare access should integrate public health and industry because policies do not consider access to medicines.7 A scoping review of medicine access suggests investigating how universal health access regulations interact with med- icine access policies8 because governance and capital affect medicine availability.9 We must study how different policy options have shaped medicine access and determine which ones are most effective.10 Mousavi11 suggests a broad approach to healthcare that considers how policies affect health out- comes and service delivery. We synthesized evidence from systematic reviews of how government policies affect LMICs’ access to medicines. In addition to narrative syn- thesis, we used realist synthesis to identify policy context.12 Existing frameworks for access to med- icine have not fully addressed the complex role of medicines in dynamic health sys- tems, as they often focus on specific pur- poses.6 Barriers to access are interrelated, occurring simultaneously at various levels of the health system and involving multiple stakeholders, which necessitates a health system view for implementing effective reforms. By adopting a complex adaptive systems lens, the framework proposed by Bigdeli et al. identifies linkages, relevant stakeholders, and context for scaling up existing small-scale or fragmented access to medical interventions. This comprehensive view of the complexity of access barriers, enablers, and their interactions stimulates a deeper understanding of access to medicine issues. Applying complex systems thinking in health system strengthening is limited, and documented examples of access to medicine are rare. However, several options for overcoming these challenges and mov- ing the systems thinking agenda forward have been proposed. These options include systematically exploring issues from a health system perspective, fostering more system-wide planning, evaluation, and research, and building a community of prac- tice. Tax reduction policies, policies that cap the maximum price charged to the gov- ernment, and policies that establish or encourage health technology assessment agencies can improve access to medicines in low- and middle-income countries. By addressing quantification and acquisition errors, therapeutic choices, and other situa- tional factors, policymakers can create a more comprehensive and effective approach to improving access to medicines. Nevertheless, some people assume that medicines are readily available on interna- tional markets therefore global procurement improves access to medicines in LMICs.13 Healthcare in Low-resource Settings 2023; volume 11:11143 Correspondence: Celestino Kuchena, PhD Business and Management as the department, University of Zambia, Lusaka, Zambia. Tel.: +263 774 179285 E-mail: elestinoc@gmail.com Key words: access; affordability; availability; medicines; policy. Contributions: CK contributed to conceptual- ization, data curation, investigation, formal analysis, writing – original draft preparation, and visualization. AQ contributed to resources, validation, supervision, and writing – review & editing. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: not applicable. Availability of data and materials: materials and data are available from the corresponding author upon request. Acknowledgments: the authors extend their heartfelt appreciation to Mr. Mhazo and Ms. Elizabeth Fleur Peacocke, a Senior Advisor at the Norwegian Institute of Public Health, for their invaluable feedback on the protocol. Received for publication: 9 January 2023. Accepted for publication: 11 July 2023 This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11143 doi:10.4081/hls.2023.11143 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher.No n- co mm er cia l u se on ly [page 54] [Healthcare in Low-resource Settings 2023; 11:11143] Consequently, health policy debates con- centrate on the content of reforms rather than the actors involved in policy reform or local contexts.14 Although several authors have written on health supply chains and policies,15-18 there is agreement on a research gap in health system studies to inform policymaking to which declining pharmaceutical sectors act as an impetus for policy research.19 It is, therefore, critical to review the evidence synthesized on access to drugs to see if it addresses policy interre- lationships. Objective With this article, we sought to collate evidence from systematic review papers on how policies can affect access to medicines. Materials and Methods Though there are various types of reviews, selecting one that addresses perti- nent clinical, or policy questions is criti- cal.20 Koon et al.21 argue that policy inter- pretations based on a constructivist approach converge on accepting multiple perspectives on societal concerns. This con- structivist approach served as the founda- tion for our rapid review. We intended to find, appraise, and detail findings only from systematic reviews of access to medicines in the context of policies.22 No study has compiled evidence from systematic reviews of policies affecting access to medicines. By pooling these systematic review papers, we assessed the information available and gaps in the literature on how and which policies influence access to medicines and medical supplies. Due to time constraints, we could not include primary studies and other forms of evidence.23 We chose a rapid review to shorten timelines and avoid miss- ing a policy “window of opportunity”24 because Zimbabwe has elections in 2023. There was no need for ethical approval because this was a rapid review. Framework We refined our inclusion criteria using Munn et al.’s population, the phenomenon of interest, and the context (PICo) frame- work.20 For the population, we concentrated on people living in low- to middle-income countries. We were interested in health, industrial, economic, and other policies that affect access to medicines. We chose sys- tematic reviews published between 2019 and November 2nd, 2022, to include only studies published after the start of COVID- 19. We did not concentrate on a specific outcome statement or comparator because this was a text review.20 Search strategy We used the search criteria below and modified them to fit the search database by removing Boolean operators as needed. In line with the literature,25 only one reviewer (CK) conducted the searches and screened the documents for inclusion. The other reviewer (AQ) helped develop the search criteria and conducted preliminary investi- gations to validate them. We created a review protocol and registered it on PROS- PERO as CRD42022370376. Furthermore, in the second search, we left any reference to policy in the search criteria to widen the pool of articles from which to choose. Relying on a seminal paper,26 we adapted principles from qualitative research and strived for heterogeneity in the studies. Search criterion Medicines are accessible if they are available, affordable, and acceptable, and people can obtain them.27 We also disaggre- gated “access to medicines” into its compo- nents using the three frameworks.6 WHO-MSH 2000: availability, accessi- bility, affordability, or acceptability of (medicines or drugs) and “systematic review.” WHO (2004c): “rational use or afford- able price or sustainable financing or reli- able health and supply systems” (of medi- cines or drugs) AND systematic review Frost & Reich (2010): (availability, affordability, or adoption) of medicines AND systematic review. Using the above definition of access to medicines, we came up with the following search criteria: the initial criteria (First search) were “policy” AND “access to med- icines” AND “systematic review” OR “policing” AND “access to medicines” AND “systematic reviews” OR “access to drugs” AND “policy” AND “systematic review” OR “access to medicines” AND “policy” AND “systematic review” OR “policy” AND “access to drugs” AND “sys- tematic review”. We removed reference to policy for the second search to broaden the search results. Databases We used Harzing’s Publish or Perish (Windows GUI Edition) 8.5.4149.8315 software to search on CrossRef, Scopus, PubMed, OpenAlex, Semantic Scholar, and Google Scholar. We set all searches to a maximum of 1000 results. Manual searching The review aimed for an interpretive explanation;27 therefore, we followed up on some references to explore thematic leads. We searched the literature for studies on the suggested policy recommendations. Eligibility criteria We focused on systematic reviews of articles published in English between 2019 and 2022 on policies and access to medi- cines in LMICs. Because of the perceived impact of COVID-19, we chose 2019 as the cutoff date. Furthermore, we had to cover a period that started only three years ago fol- lowing Dobbins’28 recommendation to syn- thesize using evidence within three years of publication, and we did it in the context of low-income countries. We excluded articles that did not meet these criteria. We also excluded reviews that did not evaluate the quality of primary studies published before 2019 or focused on countries other than LMICs. Data extraction We extracted the names of the authors, article information (full citation, year of the study objective), key findings, and recom- mendations that have policy implications. We searched articles for the consequences of the policies discussed,29 how these poli- cies could affect access to medicines, and the context for policy implementation. Data synthesis We undertook a narrative synthesis30-32 and used a thematic approach to group data into themes and a textual narrative approach to provide details of the characteristics, con- text, and similarities of the studies included in the review.33 We described the policies discussed concerning access to health, high- lighted gaps in the literature, and comment- ed on the breadth of the evidence; therefore, a textual narrative synthesis was more appropriate.33 Results This review included 32 studies as shown on the PRISMA flow chart below (Figure 1). The search yielded various studies on access to medicine, which focused on dif- ferent aspects such as trade treaties, financ- ing, public access, specific condition-spe- cific medicines, anti-infectives, vaccine access, maternal and child health, noncom- municable disease medicines, sexual and reproductive health, post-abortion care, and pediatric access to medicines (Figure 2). The studies were clustered into four cate- gories: availability, usage, cost and afford- ability, and accessibility. Access to medi- cine is a fundamental component of the full realization of the right to health, and it is intrinsically linked with the principles of equality and non-discrimination, trans- parency, participation, and accountability. Article No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:11143] [page 55] Discussion We discussed the findings under com- ponents of access to medicines: availability, usage (rational), cost and affordability, accessibility, and acceptability to gain a bet- ter understanding of these challenges. Availability The are several causes for the unavail- ability of medicines. LMICs never have enough medicine34-39 while legal and moral concerns prevent prescribers and dispensers from dispensing certain drugs.40,41 The inequitable distribution of pharmacies and other health institutions39 limits medicine availability by favoring towns and under- serving the poor. Hospital subsidies also perpetuate inequality.42 Patients may not fully understand the services available. For example, palliative care39 and indiscrimi- nate antimicrobial use may be unfamiliar to the public43 so Abu-Odah et al. recommend educating the public about services avail- able and rational medicine use.44 For human capacity, reviewers recommend empower- ing health workers through training and well-framed treatment guidelines.44 This empowerment entails strengthening and updating treatment guidelines.36-7 Kibirige et al. recommended incorporating comple- mentary medicine in national health poli- cies and changing policies and laws that restrict or discourage drug access.37 Factors within the health system inter- act in complex ways to affect availability and affordability.38 Consequently, address- ing access to medicines requires harmoniz- ing multisectoral policies to improve the chances of sustainability.45,36 These policies can promote innovations and local manu- facturing to improve resilience and self- reliance. In some cases, ensuring availabili- ty is an urgent concern41 therefore interna- tional bodies should institutionalize policies that ensure equity in the global pharmaceu- tical market.46 Sekalala et al. recommend reparative justice, not through charity but through redistribution, expanding manufac- turing capacity in the global south.47 By working together, governments, interna- tional organizations, and the private sector can create a more equitable environment for access to medicines ensuring that all indi- viduals have the opportunity to receive the healthcare they need. Usage The literature needs more evidence on how medicines are used,48 or how policy changes affect access to medicines.49 Concerns about sustainability in the absence of funding partner support hamper the adoption of new products.43 There have been reports of irrational medicine use attributed to either client demand for anti- bacterial medications or business interests pushing for profit.46,50,51 To address these issues, LMIC governments can implement policies that promote the rational use of medicines, such as establishing guidelines for the appropriate use of antibacterials and providing education to both healthcare pro- fessionals and the public.52 However, tight antibacterial dispensing regulations must be balanced with access to medicines for peo- ple in rural areas who may have difficulty obtaining prescriptions.50 Some scholars call for incentives that enhance the desired behavior and retard the unwanted behavior of health practitioners.50 Therefore, it is nec- essary to generate robust evidence on the effect of policies on patient and provider behavior and government choices.53 The urban bias in the distribution of health facilities also influences medicine usage.54 However, program-specific aid can improve geographical coverage and increase usage.43 Also, inadequate distribu- tion of available medicines decreases their use.46 Low usage of some products occurs when providers are afraid of restrictive poli- cies, despite guidelines outlining their indi- cations.54 Incorporating traditional medi- cines into health policies and insurance plans will increase and document their use.34 Though out-of-pocket expenditure for medicines was offset in some way by other payments for medical services, zero- markup policies resulted in increased medi- cine use.53 Adane et al. called for coopera- tion between traditional and conventional medicine practitioners.48 Some researchers advise incorporating traditional medicine into the referral and health insurance schemes.34 Aslam et al. suggested integrat- ing health strategies.43 Similarly, Izugbara et al. recommended pooling services such as nutritional care, gender violence, and post-abortion care.54 Equity is also a topical issue in universal health coverage discus- sions. Scholars propose covering marginal- ized communities through outreach pro- grams.43 Another option is training and using tra- ditional medicine practitioners as communi- ty health workers because people already consult traditional medicine practitioners. By implementing policies that ensure a qualified workforce, governments can Article Figure 1. PRISMA Flowchart of the screening of systematic review articles. No n- co mm er cia l u se on ly [page 56] [Healthcare in Low-resource Settings 2023; 11:11143] improve the appropriate selection, prescrip- tion, and use of medicines, reducing the risk of medication errors, adverse drug reac- tions, and antimicrobial resistance. Furthermore, well-trained healthcare providers are more likely to adhere to clini- cal guidelines and promote patient-centered care, ultimately improving patient out- comes and overall healthcare system per- formance.55-56 Cost and affordability People in LMICs, in general, cannot afford medicines.41,42,46,57,58 The costs of accessing health products are generally higher in the private sector than in the pub- lic sector.38,57 For example, women who seek sexual and reproductive healthcare face financial hardship.57 This expenditure can lead to financial catastrophe.58 These high prices arise because of insufficient price controls, public insurance schemes, limited generic manufacturing in LMICs, and the lack of co-financing arrangements.37 Innovator products are generally more expensive than their generic counterparts59 and studies show that the TRIPS Agreement increased drug prices.49 Intellectual proper- ty provisions can reduce medicine’s afford- ability.38 To improve cost and affordability, LMIC governments should consider imple- menting policies such as tax reduction, price control, and support for generic man- ufacturing. For example, some countries have reduced or eliminated taxes on essen- tial medicines, leading to lower retail prices and improved access for patients.60 Policies setting the maximum price charged to the government for medicines can also play a crucial role in controlling costs and ensur- ing affordability.61 Pricing will continue to be an issue for LMICs due to their low bar- gaining power in the international pharma- ceutical market.46 As a result, scholars have called for policies to resolve pricing con- cerns.39,54,59,62 Policy decisions require political will from leaders and assured domestic funds for sustainability.63 Policymakers should remember that organizations may respond in ways that contradict policy objectives; hospitals responded to the zero-markup pol- icy for essential drugs by raising non-drug costs to maintain their revenue.53 Subsidies given to hospitals marginalize those who use primary healthcare facilities.64 While using health service usage as a proxy, the distribution of total healthcare benefits favors the wealthy over the disadvantaged.65 As a result, socioeconomic disparities can persist or be exacerbated by well-intended policies. Overall, health insurance programs reduced the likelihood of financial disasters, though vulnerable people faced high out-of- pocket expenses.42 Health insurance schemes to decrease out-of-pocket expendi- ture can solve this.37,38 In addition, LMIC governments should consider implementing compulsory insurance policies to improve equity in access to medicines, as low cover- age by public insurance limits access due to costs.39 Another important policy approach involves establishing or encouraging health technology assessment (HTA) agencies. The use of HTA agencies in LMICs can improve access to cost-effective and high- quality medicines, while also promoting the rational use of healthcare resources.66-67 Instead of copying developed nations, LMIC governments should develop multi- pronged strategies to address their unique challenges, such as promoting local produc- tion of medicines, fostering regional coop- eration for joint procurement, and advocat- ing for fairer international trade agreements.45 At the same time, mecha- nisms that permit people to compare prices before buying can be beneficial.39 Governments are also encouraged to imple- ment economic policies that improve the public’s capacity to pay.59 This raises sever- al policy implications. Nudge behavior Governments should equip and encour- age people to use primary health centers57 and incentivize generic prescribing.39 Rules and regulations are not enough, as people and organizations can circumvent them. The policy should be consistent throughout the government, and government communi- cation must be unambiguous57 to promote the desired behavior. Local solutions for local contexts Governments in LMICs must seek and develop multisectoral strategies to address their specific challenges rather than copying solutions from developed countries.45 One Article Figure 2. Focus of the studies included. No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:11143] [page 57] option is to incentivize the manufacture of products locally while registering them preferentially.37 Despite this call for self- reliance, increasing access to medicines requires multisectoral approaches41 and global cooperation.58 International bodies, too, must promote equity in the internation- al pharmaceutical markets.46 Review of legislation and policies There is a need for policies specifically addressing medicine costs, the capacity of people to pay, and the retail prices for med- icines, for example, China implemented a “zero markup” drug policy.53 Insurance and prices based on the capacity to pay increase equity.39,64 Guidelines must be updated to reflect contextual evidence on safety, effec- tiveness, and acceptability.37 35 Accessibility Lockdown policies that restricted movement reduced access to medicines dur- ing the peak of the COVID-19 pandemic.46 Poor healthcare facilities, a shortage of health workers, and limited equipment reduce physical access to medicines.68 Transportation issues and a lack of knowl- edge about available services69 also hinder access to medicines. Some academics have proposed changes to intellectual property laws to improve access to medicines, though several factors can mitigate the impact.49 The distribution and availability of service providers are skewed toward urban facilities. This, combined with trans- portation costs, limits access for people out- side cities.54 For oncology medicines, med- icine stockouts and the lack of updated guidelines were identified as barriers to access.39 In a separate study, medicine stockouts, and high prices all reduced access to medicines.70 Subsidies and tax policies that consider one’s ability to pay to improve equity in access to medicines.64 LMIC governments should consider implementing policies that foster greater equity in healthcare facility distribution, such as investing in rural healthcare infra- structure and incentivizing health workers to serve in underserved areas, encouraging the use of telemedicine or mobile clinics to reach remote populations, as well as subsi- dize transportation costs for patients in need. Addressing both demand-side factors and supply-side factors improved access during emergencies.71 Here are some recommendations to improve accessibility: i) increase coverage for specific treatments; ii) engage key stakeholders and actors; iii) integrate serv- ices and interdisciplinary approaches; iv) develop facilities catering to special needs and vulnerabilities. Acceptability Medicines may be available, accessible, and affordable, but people might still choose not to use them due to concerns about acceptance. In a review of female condom usage, factors influencing accept- ability included male partner opinions, functionality, condom appearance, and ease of access.69 As these users became more familiar with the condoms, acceptability increased. For the human papillomavirus (HPV) vaccine, concerns about safety, effectiveness, and self-perception of risk reduced acceptance.69 People with higher incomes living in urban areas were less likely to receive the HPV vaccine, as they tended to refuse it.72 Another review exam- ined women’s acceptance of mifepristone and misoprostol for medical abortions and their effectiveness.59 In one study, fear of chemotherapy also reduced access to medi- cines.70 These findings carry several policy implications. Considering product acceptability before a product enters the market is vital to ensure that it meets the needs and prefer- ences of potential users. By consulting potential users, policymakers and manufac- turers can capture insights and improve the design and desirability of intervention pro- grams and policies. Intentional engagement with would-be end-users can lead to more successful implementation of healthcare interventions and greater satisfaction among patients. Countries must learn from Brazil’s pur- suit of several strategies to improve access to medicines for its population, including establishing a universal healthcare system, promoting domestic pharmaceutical indus- trialization, strengthening healthcare infras- tructure, developing subsidy programs, increasing transparency, supporting product development partnerships, implementing the Essential Medicines Policy (EMP) to improve the provision and use of pharma- ceuticals, creating municipal essential medicines lists (MEML) to evaluate the effects of the EMP on the procurement and availability of medicines, and implementing the Pharmacy Network of Minas program to promote improvements in essential medicine availability.73,74,75 However, entrenched inequalities within and between states have affected healthcare utilization and resulted in very different procurement prices, particularly affecting the purchasing capacity of smaller states73 As observed in Brazil, access to medicines is associated with social, economic, and health percep- tion factors.76 Therefore, educational strate- gies are key to improving access to medicines.77 Strengths and limitations of the study This study has four main strengths. Its reliance on a constructivist approach enabled a review that brings out the nuances of contextual differences. Second, the focus on systematic reviews allowed for a synthe- sis of evidence from rigorous studies. Third, limiting the articles to those published with- in three years ensured that the evidence was current and applicable given the coinci- dence with the advent of the COVID-19 pandemic. Lastly, this appears to be the first study that aggregated evidence from papers that focused on distinct health conditions or programs. One strength, however, can be viewed as a weakness. This study excluded primary studies and other forms of evidence such as grey literature. Grey literature would have offered a view into how min- istries and individual organizations working with governments view access to medi- cines. Primary studies would have provided even more contemporary and contextual evidence. Acknowledging this weakness informs our suggestions for future research areas. Future research priorities Researchers must seek evidence to inform cross-sector strategies45 and use mixed-methods studies to evaluate pro- grams.63 Such research can help explicate why some researchers could not explain why medical services increased in China following a new policy on medicine markups.53 We must collect more data on the factors influencing access to medicines in LMICs38,41, and assess vulnerability and power distribution when analyzing these factors.42 Several authors agree on the need for more research in LMICs to generate evi- dence on general or specific components of access to medicines.38,41,78 Countries should encourage and reward researchers who con- duct research in local contexts. Conclusions Policymaking requires context because healthcare reform is more political than technical.67 Breaking medical care barriers requires sociocultural knowledge, but empirical public health research ignores sociopolitical contexts.80 Issue framing is important because organization frames strengthen meaning by emphasizing one evaluative dimension and elevating it above other valued goals, such as prioritizing access to life-saving medicines over intel- lectual property rights.81 Communication is, therefore, vital because learning about a policy’s positive and negative outcomes can Article No n- co mm er cia l u se on ly [page 58] [Healthcare in Low-resource Settings 2023; 11:11143] increase or decrease support for the policy.82 Policy failure can result from policy ideas and implementers’ assumptions clash- ing.83 Removing user fees lowers household health spending and increases poor people’s use of formal healthcare, but Africa’s polit- ical and institutional challenges make fee removal difficult. Investing in primary care and removing barriers increases equity.56 Furthermore, policies that define the maxi- mum price charged to the government and that establish or encourage health technolo- gy assessment agencies can be part of the discussion, as they can help improve access to medicines in LMICs. These policies can be adopted to regulate medicine prices and ensure the rational use of medicines based on evidence and cost-effectiveness. In summary, to effectively improve access to medicines in LMICs, policymak- ers must consider the complex interplay of various factors and develop multipronged strategies that address the unique challenges faced by their populations. LMIC govern- ments can work towards reducing social inequities and health disparities while ensuring equitable access to essential medi- cines for all. Policies that guarantee a qual- ified workforce should be discussed, as these can influence rational use. This can involve investing in the training of health- care professionals, implementing strict reg- ulations to promote rational prescribing and dispensing practices, and monitoring the performance of health institutions to ensure quality service delivery. To address these policy implications, LMIC governments should consider developing policies that target the specific barriers faced by different population groups by implementing target- ed health education campaigns to raise awareness about the importance of medi- cine access and adherence, training health- care providers in culturally competent care, and addressing the stigma around certain health conditions. Pricing and financing policies should increase coverage for vul- nerable groups83 by subsidizing products.35 References 1. Montagu D, Goodman C. Prohibit, con- strain, encourage, or purchase: how should we engage with the private health-care sector? Lancet 2016;388: 613-21. 2. Montagu D, Goodman C, Berman P, Penn A, Visconti A. Recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions. Health Policy Plann 2016;31:1117-32. 3. Grépin KA. Private sector an important but not dominant provider of key health services in low-and middle-income countries. Health Affairs 2016;35:1214- 21. 4. Morgan R, Ensor T, Waters H. Performance of private sector health care: implications for universal health coverage. Lancet 2016;388:606-12. 5. McPake B, Hanson K. Managing the public–private mix to achieve universal health coverage. Lancet 2016;388:622- 30. 6. Bigdeli M, Jacobs B, Tomson G, et al. Access to medicines from a health sys- tem perspective. Health Policy Plann 2013;28:692-704. 7. Townsend B. Defending access to medi- cines in regional trade agreements: les- sons from the Regional Comprehensive Economic Partnership–a qualitative study of policy actors’ views. Globalization Health 2021;17:1-14. 8. Perehudoff K, Demchenko I, Alexandrov NV, et al. Essential medicines in univer- sal health coverage: a scoping review of public health law interventions and how they are measured in five middle- income countries. Int J Environ Res Public Health 2020;17. 9. Odoch WD, Dambisya Y, Peacocke E, et al. The role of government agencies and other actors in influencing access to medicines in three East African coun- tries. Health Policy Plann 2021;36:312- 21. 10. Peprah Boaitey K, Tuck C. Advancing health system strengthening through improving access to medicines: A review of local manufacturing policies in Ghana. Medicine Access@ Point of Care. 2020;4:2399202620962299. 11. Mousavi T, Nikfar S, Abdollahi M. Achieving equitable access to medi- cines and health services: a COVID-19- time recalled matter. Iran J Pharm Res 2021;20:450. 12. Jagosh J. Realist synthesis for public health: building an ontologically deep understanding of how programs work, for whom, and in which contexts. Ann Rev Public Health 2019;40:361-72. 13. Mackintosh M, Mugwagwa J, Banda G, Tunguhole J. Local production of phar- maceuticals and health system strength- ening in Africa: an evidence brief. In German Health Practice Collection (GHPC), Berlin; 2017. 14. Walt G, Gilson L. Reforming the health sector in developing countries: the cen- tral role of policy analysis. Health Policy Plann 1994;9:353-70. 15. Mackintosh M, Tibandebage P, Karimi Njeru M, et al. Rethinking health sector procurement as developmental linkages in East Africa. Soc Sci Medi 2018;200: 182-9. 16. Lugada E, Komakech H, Ochola I, et al. Health supply chain system in Uganda: current issues, structure, performance, and implications for systems strength- ening. J Pharm Policy Practice 2022; 15:1-11. 17. Mwagomba BL, Ameh S, Bongomin P, et al. Opportunities and challenges for evidence-informed HIV-noncommuni- cable disease integrated care policies and programs: lessons from Malawi, South Africa, Swaziland and Kenya. AIDS 2018;1;32:S21-S32. 18. Mulumba M, Machemedze R. Addressing bottlenecks to local produc- tion of medicines: Issues for interna- tional co-�operation in East and Southern Africa. J Health Dipl 2015;1. 19. Tibandebage P, Wangwe S, Mackintosh M, et al. Pharmaceutical manufacturing decline in Tanzania: how possible is a turnaround to growth? In Mackintosh M, Banda G, Tibandebage P, Wamae W, editors. Making medicines in Africa. International Political Economy Series. London: Palgrave Macmillan; 2016. 20. Munn Z, Stern C, Aromataris E, et al. What kind of systematic review should I conduct? A proposed typology and guidance for systematic reviewers in the medical and health sciences. BMC Med Res Methodol 2018;18:5. 21. Koon AD, Hawkins B, Mayhew SH. Framing and the health policy process: a scoping review. Health Policy Plann 2016;31:801-16. 22. Oliver S, Bangpan M, Dickson K. Producing policy relevant systematic reviews: navigating the policy-research interface. Evidence Policy 2018;14:197-220. 23. Wilson M, Lavis J, Gauvin FP. Developing a rapid-response program for health system decision-makers in Canada: Findings from an issue brief and stakeholder dialogue. Systematic Reviews 2015;4. 24. Wilson MG, Oliver S, Melendez-Torres GJ, et al. Paper 3: Selecting rapid review methods for complex questions related to health policy and system issues. Systematic Reviews 2021;10:286. 25. Haby M, Chapman E, Clark R, et al. What are the best methodologies for rapid reviews of the research evidence for evidence-informed decision making in health policy and practice: A rapid review. Health Res Policy Syst 2016;14. 26. Thomas J, Harden A. Methods for the Thematic Synthesis of Qualitative Research in Systematic Reviews. BMC Article No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:11143] [page 59] Med Res Methodol 2008;8:45. 27. Doyle LH. Synthesis through meta- ethnography: paradoxes, enhancements, and possibilities. Qual Res 2003;3:321- 44. 28. Dobbins M. Rapid Review Guidebook Hamilton: National Collaborating Centre for Methods and Tools; 2017. 29. Mirzoev T, Koduah A, Chavez AC, et al. Implementation of medicines pricing policies in sub-Saharan Africa: protocol for a systematic review. BMJ Open 2021;11:044293. 30. Popay J, Roberts H, Sowden A, et al. Guidance on the conduct of narrative synthesis in systematic reviews. A prod- uct from the ESRC methods programme Version. 2006. 31. Thomson H, Campbell M. Narrative synthesis” of quantitative effect data in Cochrane reviews: Current issues and ways forward [Internet: Cochrane Learning Live Webinar Series]; 2020. 32. Campbell M, McKenzie JE, Sowden A, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: report- ing guideline. BMJ 2020;368:l6890. 33. Lucas PJ, Baird J, Arai L, et al. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews. BMC Med Res Methodol 2007;7:1-7. 34. Kim JK, Kim KH, Shin YC, et al. Utilization of traditional medicine in primary health care in low- and middle- income countries: a systematic review. Health Policy Plann 2020;35:1070-83. 35. Wang D, Wu J, Du J, et al. Acceptability of and barriers to human papillomavirus vaccination in China: A systematic review of the Chinese and English sci- entific literature. Eur J Cancer Care 2022;31:e13566.. 36. Albelbeisi AH, Albelbeisi A, El Bilbeisi AH, et al. Public sector capacity to pre- vent and control of noncommunicable diseases in twelve low- and middle- income countries based on WHO-PEN standards: a systematic review. Health Serv Insights 2021;14:1178632920986233. 37. Kibirige D, Sanya RE, Nantanda R, et al. Availability and affordability of medicines and diagnostic tests recom- mended for management of asthma and chronic obstructive pulmonary disease in sub-Saharan Africa: a systematic review. Allergy Asthma Clinical Immunol 2019;15:14. 38. Lotfizadeh A, Palafox B, Takallou A, et al. Factors associated with the availabil- ity and affordability of essential cardio- vascular disease medicines in low- and middle-income countries: A systematic review. PLOS Global Public Health 2022;2:1-18. 39. Ocran Mattila P, Ahmad R, Hasan SS, Babar ZU. Availability, affordability, access, and pricing of anti-cancer medi- cines in low- and middle-income coun- tries: a systematic review of literature. Front Public Health 2021;9:628744. 40. Ferguson I, Scott H. Systematic review of the effectiveness, safety, and accept- ability of mifepristone and misoprostol for medical abortion in low- and mid- dle-income countries. J Obst Gynaecol Canada 2020;42:1532-1542.e2. 41. Stolbrink M, Thomson H, Hadfield RM, et al. The availability, cost, and afford- ability of essential medicines for asthma and COPD in low-income and middle- income countries: a systematic review. Lancet Global Health 2022;10:e1423— 42. 42. van Hees SGM, O’Fallon T, Hofker M, et al. Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a system- atic review. Int J Equity Health 2019;18:134. 43. Aslam F, Ali I, Babar Z, Yang Y. Building evidence for improving vac- cine adoption and uptake of childhood vaccinations in low- and middle-income countries: a systematic review. Drugs Ther Perspect 2022;38:133-45. 44. Abu-Odah H, Molassiotis A, Liu J. Challenges on the provision of pallia- tive care for patients with cancer in low- and middle-income countries: a system- atic review of reviews. BMC Palliative Care 2020;19:55. 45. Ifeagwu SC, Yang JC, Parkes-Ratanshi R, Brayne C. Health financing for uni- versal health coverage in Sub-Saharan Africa: a systematic review. Global Health Res Policy 2021;6:8. 46. Boro E, Stoll B. Barriers to COVID-19 health products in low-and middle- income countries during the COVID-19 pandemic: a rapid systematic review and evidence synthesis. 2022. 47. Sekalala S, Forman L, Hodgson T, et al. Decolonizing human rights: how intel- lectual property laws result in unequal access to the COVID-19 vaccine. BMJ Global Health 2021;6:e006169. 48. Adane F, Seyoum G, Alamneh YM, et al. Herbal medicine use and predictors among pregnant women attending ante- natal care in Ethiopia: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2020;20:157. 49. Islam MD, Kaplan WA, Trachtenberg D, et al. Impacts of intellectual property provisions in trade treaties on access to medicine in low and middle income countries: a systematic review. Globalization Health 2019;15:88. 50. Porter G, Owens S, Breckons M. A sys- tematic review of qualitative literature on antimicrobial stewardship in Sub- Saharan Africa. Global Health Res Policy 2021;6. 51. Belachew SA, Hall L, Selvey LA. Non- prescription dispensing of antibiotic agents among community drug retail outlets in Sub-Saharan African coun- tries: a systematic review and meta- analysis. Antimicrob Resist Infection Control 2021;10:13. 52. Sartelli M, Hardcastle C, Catena T, et al. In use in low and middle-income coun- tries and the challenges of antimicrobial resistance in surgery. Antibiotics Basel 2020;9:497. 53. Liu WY, Hsu CH, Liu TJ, et al. Systematic review of the effect of a zero-markup policy for essential drugs on healthcare costs and utilization in China, 2015-2021. Frontiers Med 2021;8. 54. Izugbara C, Wekesah FM, Sebany M, et al. Availability, accessibility and utiliza- tion of post-abortion care in Sub- Saharan Africa: A systematic review. Health Care Women Int 2020;41:732- 60. 55. Bader L, Bates I, Schneider P, Charman W. Transforming pharmacy and phar- maceutical sciences education in the context of workforce development. UCL Discovery, 2017. Available from: https://discovery.ucl.ac.uk/id/eprint/155 4666/ 56. Wong A, Hung KK, Mabhala M, et al. Filling the gaps in the pharmacy work- force in post-conflict areas: experience from four countries in Sub-Saharan Africa. Int J Environ Res Public Health 2021;18:8132. 57. Banke-Thomas A, Ayomoh FI, Abejirinde IOO, et al. Cost of utilising maternal health services in low- and middle-income countries: a systematic review. Int J Health Policy Manag 2021;10:564-577. 58. Moucheraud C, Lenz C, Latkovic M, Wirtz VJ. The costs of diabetes treat- ment in low- and middle-income coun- tries: a systematic review. BMJ Glob Health 2019;4:e001258. 59. Chen Z, Li S, Zeng L, et al. Accessibility of Medicines for Children: A Systematic Review. Frontiers Pharmacol 2021;12:691606. 60. Ewen M, Zweekhorst M, Regeer B, Laing R. Baseline assessment of WHO’s target for both availability and affordability of essential medicines to treat non-communicable diseases. PloS Article No n- co mm er cia l u se on ly [page 60] [Healthcare in Low-resource Settings 2023; 11:11143] One 2017;12:0171284. 61. Bashaar M, Hassali MA, Saleem F, et al. Efficacy of international approaches to medicine price regulation and control: a scoping review. J Appl Pharmaceut Sci 2017;7:227-41. 62. Latifah E, Kristina S, Suryawati S, Ali Kusnadi S. Overview of drug availabil- ity and influencing factors in several low, lower and upper- middle countries: a systematic review. Systematic Rev Pharm 2018;10:67-72. 63. James N, Lawson K, Acharya Y. Evidence on result-based financing in maternal and child health in low- and middle-income countries: a systematic review. Global Health Res Policy 2020;5:31. 64. Rostampour M, Nosratnejad S. A sys- tematic review of equity in healthcare financing in low- and middle-income countries. Value Health Regional Issues 2020;21:133-40. 65. Asante A, Price J, Hayen A, et al. Equity in health care financing in low-and mid- dle-income countries: a systematic review of evidence from studies using benefit and financing incidence analy- ses. PloS One 2016;11:e0152866. 66. Alkhaldi M, Al Basuoni A, Matos M, et al. Health technology assessment in high, middle, and low-income coun- tries: new systematic and interdiscipli- nary approach for sound informed-poli- cy making: research protocole. Risk Manag Healthc Policy 2021;14:2757- 70. 67. Hollingworth S, Fenny AP, Yu SY, et al. Health technology assessment in sub- Saharan Africa: a descriptive analysis and narrative synthesis. Cost Eff Resour Alloc 2021;19:39. 68. El-Jardali F, Fadlallah R, Daouk A, et al. Barriers and facilitators to implementa- tion of essential health benefits package within primary health care settings in low-income and middle-income coun- tries: A systematic review. Int J Health Plann Manag 2019; 34:15-41. 69. Ganle JK, Baatiema L, Quansah R, Danso-Appiah A. Barriers facing per- sons with disability in accessing sexual and reproductive health services in sub- Saharan Africa: A systematic review. PloS One 2020;15:e0238585. 70. Salisu WJ, Mirlashari J, Varaei S, Seylani K. Limited access to care for persons with breast cancer in Africa: A systematic review. Eur J Oncol Nursing 2021;50:101867. 71. Song K, Lee A. Factors influencing the effective management of diabetes dur- ing humanitarian crises in low- and middle-income countries: a systematic review. Public Health 2021;199:110-7. 72. Fasehun LK, Lewinger S, Fasehun O, Brooks M. Barriers and facilitators to acceptability of the female condom in low- and middle-income countries: a systematic review. Ann Global Health 2022;88:20. 73. Thorsteinsdóttir H, Ovtcharenko N, Kohler JC. Corporate social responsi- bility to improve access to medicines: the case of Brazil. Globalization Health 2017;13:1-1. 74. Barbosa MM, Nascimento RC, Garcia MM, et al. Strategies to improve the availability of medicines in primary health care in Brazil: findings and implications. J Compar Effectiv Res 2020;10:243-53. 75. Nunn A, Fonseca ED, Gruskin S. Changing global essential medicines norms to improve access to AIDS treat- ment: Lessons from Brazil. Global Public Health 2009;4:131-49. 76. Leal AA, Rodrigues Galvão MH, Medeiros AD, Roncalli ÂG. Access to medicines among the Brazilian popula- tion based on the 2019 National Health Survey. PloS One 2023;18:e0280599. 77. Machado FLDS, Dos Santos DMSS, Lopes LC. Strategies to approach medi- cines litigation: an action research study in Brazil. Front Pharmacol 2021;12:612426. 78. Iwu CJ, Ngcobo N, Jaca A, et al. A sys- tematic review of vaccine availability at the national, district, and health facility level in the WHO African Region. Expert Rev Vacc 2020;19:639-51. 79. Walt G, Gilson L. Reforming the health sector in developing countries: the cen- tral role of policy analysis. Health Policy Plann 1994;9:353-70. 80. Tharumia Jagadeesan C, Wirtz VJ. Geographical accessibility of medi- cines: a systematic literature review of pharmacy mapping. J Pharmaceut Policy Practice 2021;14:1-3. 81. Steele P, Subramanian L, Tolani F. Interventions to improve access to med- icine in developing countries: mapping WHO’s building blocks and supply chain functions. Acta Sci Pharm Sci 2019;3:111-20. 82. Nguyen A. Challenges for women with disabilities accessing reproductive health care around the world: a scoping review. Sexuality Disability 2020;38:371-88. 83. Tahir A, Abdilahi AO, Farah AE. Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta- analysis, 2016-2020. Health Econom Rev 2022;12:38. Article No n- co mm er cia l u se on ly