School of Pharmacy, University of the Western Cape, Private Bag X17, Bellville, 7535 Cape Town, South Africa. b

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1 Reserch Assessing equity in the geogrphicl distribution of community phrmcies in South Afric in preprtion for ntionl helth insurnce scheme Kim Wrd, Dvid Snders, b Henry Leng b & Allyson M Pollock c Objective To investigte equity in the geogrphicl distribution of community phrmcies in South Afric nd ssess whether regultory reforms hve furthered such equity. Methods Dt on community phrmcies from the ntionl deprtment of helth nd the South Africn phrmcy council were used to nlyse the chnge in community phrmcy ownership nd density (number per residents) between 1994 nd 2012 in ll nine provinces nd 15 selected districts. In ddition, the density of public clinics, lone nd with community phrmcies, ws clculted nd compred with ntionl benchmrk of one clinic per residents. Interviews were conducted with nine ntionl experts from the phrmcy sector. Findings Community phrmcies incresed in number by 13% between 1994 nd 2012 less thn the 25% popultion growth. In 2012, community phrmcy density ws higher in urbn provinces nd ws eight times higher in the lest deprived districts thn in the most deprived ones. Mldistribution persisted despite the growth of corporte community phrmcies. In 2012, only two provinces met the 1 per benchmrk, lthough ll provinces chieved it when community phrmcies nd clinics were combined. Experts expressed concerns tht lck of rurl incentives, inpproprite licensing criteri nd shortge of phrmcy workers could undermine ccess to phrmceuticl services, especilly in rurl res. Conclusion To reduce inequity in the distribution of phrmceuticl services, new policies nd legisltion re needed to increse the stffing nd presence of phrmcies. Introduction Inequities in helth nd helth-cre re well documented in South Afric. 1 4 The well-funded privte sector ttrcts the mjority of the country s helth professionls 5 nd there is shortge nd mldistribution of key helth-cre workers, including phrmcists, cross rurl urbn nd public privte sector divides. 6 South Afric s government is developing ntionl helth insurnce scheme with two objectives: to protect the poor from finncil risks nd to increse privte sector prticiption. 7 Until 1994, South Afric s privte nd public phrmceuticl services hd been concentrted in urbn metropolitn res, where the mjority of the country s middle- nd upperincome citizens lived. 8 Post-prtheid ntionl drug policy nd regultory interventions were designed to improve equity in ccess to medicines Although more thn 80% of South Africns hve ccess to free primry helth cre services nd medicines from public sector clinics nd community helth centres (herefter combined nd referred to s public clinics ), some prefer to use privte community phrmcies (community phrmcies), where witing times re shorter nd services re more ccessible. 6,12 The green pper for the ntionl helth insurnce scheme hs identified privte community phrmcies s potentil ccess points for medicines, in combintion with public clinics. 7 Community phrmcies represent two thirds of ll phrmcies registered with the South Africn phrmcy council (SAPC); the remining third comprises public institutionl, mnufcturing, wholesle, privte institutionl nd consultnt phrmcies. 6 Community phrmcies re clssified s either corporte or independently owned. Corporte community phrmcies re owned by lrge public or privte compnies, such s supermrket chins with in-store dispensries nd chins with phrmcy-only business. Corporte community phrmcies lso own wholesle nd distribution compnies nd mny re cquiring courier phrmcies. Independent community phrmcies re generlly owned nd mnged by one or more phrmcists. Most independent nd corporte community phrmcies in both urbn nd rurl res deliver primry cre services, such s chronic disese mngement, helth eduction nd promotion, mternl nd child helth cre nd immuniztion. 13 Some corporte community phrmcies re in prtnership with provincil helth deprtments to offer free fmily plnning nd childhood vccintion services. 14 To operte in South Afric, phrmcy must obtin licence from the ntionl deprtment of helth. The deprtment of helth issues one-off licences nd enforces regultions tht restrict the entry of community phrmcies, depending on need. The criteri re primrily distnce from other dispensing services (not within 500 metres, with exceptions) nd density (t most 2 community phrmcies per residents, with exceptions for shopping mlls nd rurl towns). Community phrmcies must be registered with the SAPC nd comply with good phrmcy prctice stndrds. Registrtion is renewed nnully. 10 School of Phrmcy, University of the Western Cpe, Privte Bg X17, Bellville, 7535 Cpe Town, South Afric. b School of Public Helth, University of the Western Cpe, Cpe Town, South Afric. c Centre for Primry Cre nd Public Helth, Queen Mry University of London, London, Englnd. Correspondence to Kim Wrd (emil: (Submitted: 11 September 2013 Revised version received: 30 Jnury 2014 Accepted: 31 Jnury 2014 Published online: 9 My 2014 ) 482 Bull World Helth Orgn 2014;92: doi:

2 Kim Wrd et l. Reserch Severl regultory chnges hve been mde to the Medicines nd Relted Substnces Control Act, 1965, 11 nd to the Phrmcy Act, 1974, 10 to promote the equitble distribution of phrmceuticl services nd enhnced ccess to medicines. Section 22 A (15) uthorizes phrmcists working in rurl community phrmcies who hve the necessry trining, to dignose ilments nd prescribe medicines beyond their trditionl scope of prctice. The grnting of such permits ws suspended in In ddition, dispensing licence regultions uthorize doctors nd nurses to deliver phrmceuticl services in res where need cn be demonstrted. 11 In 2003, the restrictions on phrmcy ownership with respect to the number of phrmcies owned nd the qulifictions of the owner were lifted nd corporte community phrmcies were llowed to enter the mrket. Furthermore, licensing restrictions were introduced to control the geogrphicl loction of new community phrmcies. 10 The price of medicines in the privte sector becme strictly regulted. 11 To monitor equity in ccess to helth services, the World Helth Orgniztion (WHO) hs recommended model for ssessing helth service vilbility. In this model, the number of helth cre fcilities, both public nd privte, per residents is one of the prime indictors. WHO dvoctes monitoring this indictor down to the district level for more ccurte ssessment of rurl urbn clinic distribution. 15 Diminishing gps between the most nd lest dvntged popultions resulting from policy chnges suggests tht progress towrds equitble distribution is being mde. 16 South Afric s district helth brometer monitors equity in primry helth cre provision e.g. primry helth cre expenditure per cpit, vccine coverge, length of sty in hospitl, etc. in 52 districts ccording to deprivtion indices, mesure of poverty tht includes ssets, employment, eduction nd living environment. The index rnges from 0 to 5, with the lest deprived districts represented by < 1 nd the most deprived by 5. However, the helth brometer does not provide sttistics on the densities of public clinics or ny privte fcilities. 17 The primry im of this study ws to exmine chnges in the ownership nd geogrphicl distribution of community phrmcies between 1994 nd 2012 by using routine ntionl dt. We looked t the numbers of community phrmcies per residents t the provincil level nd in selected districts nd interviewed ntionl phrmcy experts bout their perceptions of the extent to which current regultions improve the geogrphicl distribution of community phrmcies. We summed community phrmcies nd public clinics to ssess their combined provincil distribution ptterns ginst South Africn benchmrk of one clinic per residents. 18 Methods Geogrphicl distribution Dt source Community phrmcy licence pplictions were obtined from the licensing unit of the deprtment of helth nd community phrmcy registrtions were cquired from the SAPC from November to December 2012, while community phrmcy registrtions for 1994 were retrieved from published reports. 19 We found internl discrepncies in the dt from the deprtment of helth licence dtbse (My 2003 to December 2012) nd identified fewer licences pproved by the deprtment of helth thn new community phrmcy registrtions with the SAPC. Although SAPC dt were deemed more relible, they do not clssify community phrmcies by ownership. Furthermore, their registers re routinely updted nd exclude deregistered community phrmcies. For these resons, for ownership trends we relied on limited deprtment of helth ppliction dt set for 2008 to 2011; to ssess new nd existing registrtions for 2012 we relied on the current SAPC register. Dt on public clinics were obtined from the ntionl udit of helth fcilities. 20 Popultion mid-yer estimtes were sourced from the country s ntionl sttisticl service. 21,22 Dt nlysis Fcility density (i.e. number of fcilities per residents) t the provincil level ws clculted from dt on community phrmcy registrtions nd public clinics nd from popultion dt for the corresponding geogrphicl res. These were ssessed for rurl urbn disprities nd ginst benchmrk of one clinic per residents. 18 Community phrmcies were physiclly mpped nd counted t the district level using district popultion dt before computing community phrmcy densities. 21 For mpping purposes, community phrmcy serches in the ntionl SAPC register (s on 21 November 2012) were run ginst compiled lists of cities, towns nd suburbs in 15 districts (i.e. five districts ech from the lowest, highest nd middle quintile deprivtion indices). 17 The mpping for ech district ws done independently by seprte reserchers nd the findings were cross-checked for nomlies. Phrmcy expert interview We purposively selected nine ntionl experts on phrmcy regultions nd invited them to be interviewed for pproximtely two hours t their respective workplces between Mrch 2012 nd August The interviews were unstructured nd prticipnts were sked to tlk bout their views on the impct of the regultory reform on ccess to medicines nd equity in such ccess. We piloted the interview with three prctising community phrmcists nd estimted empiriclly tht eight prticipnts would chieve dt sturtion. Consent to prticipte ws given by ll selected stkeholders. These were two rurl phrmcists with section 22 A (15) permits who lso represented phrmcies t the provincil nd ntionl levels; two directors of professionl services for mjor supermrket phrmcy chins; four representtives of the Phrmceuticl Society of South Afric; nd the chirperson of the Independent Community Phrmcy Assocition of South Afric. Ethicl pprovl ws obtined from the University of the Western Cpe nd the Director-Generl of Helth t the ntionl deprtment of helth. Ech interview ws led by the principl investigtor in the presence of one of the co-reserchers. Interviews were trnscribed from udio recordings nd subsequently checked for ccurcy ginst field notes nd/or the originl udio recording. Personl identifiers were removed from trnscripts to ensure nonymity. The dt were coded in qulittive dt nlysis softwre MAXQDA (VERBI GmBH, Berlin, Germny), nd themes were identified from the dt by the reserch tem. Bull World Helth Orgn 2014;92: doi: 483

3 Reserch Kim Wrd et l. Fig. 1. Annul licence pplictions for community phrmcies, South Afric, 2008 to 2011 Number of licence pplictions Results unknown Yer Corporte community phrmcies Independent community phrmcies (closed corportions, prtnerships, sole proprietors) n = 1124, excludes eight pplictions without n ownership clssifiction. Dt source: Deprtment of helth licence dtbse, pplictions by ownership ctegory. Geogrphicl distribution Between 2008 nd 2011, 1132 new community phrmcy licence pplictions, ctegorized by ownership, were recorded by the deprtment of helth. Fewer thn 5% of them were rejected. Corporte community phrmcy pplictions incresed from 94 in 2008 to pek of 223 in 2010, nd then dropped to 48 in Independent community phrmcy pplictions incresed from 148 in 2008 to pek of 197 in 2009 nd dropped to 26 in 2011 (Fig. 1). The totl number of community phrmcies registered with the SAPC incresed by 13% between 1994 nd 2012 in the country s whole nd incresed in ll provinces except two (Tble 1). However, the growth in community phrmcies did not keep pce with the 25% increse in popultion over the sme period. Therefore, community phrmcy density fell in ll but two rurl provinces nd one urbn province. 23 The differences in community phrmcy density between the most rurl nd lest rurl provinces decresed from 1.3 per residents to 0.72 per residents between 1994 nd However, in 2012 community phrmcy density ws still higher in Guteng nd Western Cpe, the two most urbn provinces. When community phrmcy density rtes were compred ginst the deprivtion index, we found negtive correltion nd noted n eightfold difference between the most nd the lest deprived districts (OR Tmbo nd Cpe Metropole, respectively) (Fig. 2).There were vritions within provinces; OR Tmbo, one of the most deprived districts of the Estern Cpe province, hs 0.11 community phrmcies per residents, while the verge density of community phrmcies in the province is 0.34 (Tble 1 nd Fig. 2). The dt lso show lrge differences in community phrmcy density between districts with similr deprivtion indices (Fig. 2). In 2012 there were lrge vritions in the density of public clinics nd community phrmcies between provinces (Fig. 3). The benchmrk of t lest one clinic per residents 18 ws only met in two provinces, but fter pooling public nd privte fcilities (on the premise tht ll community phrmcies could offer defined pckge of primry helth cre services), ll provinces met the benchmrk t the provincil level. Pooling community phrmcies nd public clinics lso resulted in lower inequity in fcility distribution between rurl nd urbn provinces. Tble 1. Chnges in provincil community phrmcies nd popultion between 1994 nd 2012, South Afric Province (rnked from most to lest rurl) No. of registered community phrmcies b Community phrmcy growth (%), Popultion growth c (%), Community phrmcy density d Limpopo Estern Cpe Mpumlng North West KwZulu-Ntl Free Stte Northern Cpe Western Cpe Guteng Ntionl e Bsed on the rurl percentge for ech province reported by Sttistics South Afric, 2001 census. 23 b Source: L Gilbert (1994). 19 SAPC (2012). c Source: Sttistics South Afric (1994) 22 nd Helth System Trust (2012). 21 d Number of community phrmcies per residents. e Excluding three community phrmcies not ssigned to province in the register. 484 Bull World Helth Orgn 2014;92: doi:

4 Kim Wrd et l. Fig. 2. The reltionship between community phrmcy density nd deprivtion index in 15 selected districts, South Afric, 2012 Number of community phrmcies per popultion West Cost Overberg Perceptions surrounding regultion Cpe Metropole Cpe Winelnds Nmkw Seven of the nine key informnts felt tht regultory reform through ly ownership nd licensing regultions hs not reversed the inequitble distribution Gert Sibnde Bojnl Pltinum Umgungundlovu Nkngl Wterberg Zululnd Alfred Nzo Umkhnykude O R Tmbo Umzinythi Deprivtion index < 1 corresponds to the lest deprived district nd 5 to the most deprived. Note: Number of community phrmcies per residents. Dt source: community phrmcy dt: SAPC register on 21 November Popultion dt re district mid-yer estimtes for Deprivtion indices sourced from the District Helth Brometer. 17 Fcilities per residents Fig. 3. Provincil density of community phrmcies, public clinics nd pooled fcilities, b South Afric, Estern Cpe Free Stte Public clinics Pooled fcilities Guteng KwZulu-Ntl Limpopo Mpumlng Community phrmcies South Africn norm for public clinics North West Northern Cpe Western Cpe Ntionl (verge) Number of fcilities per residents. b Pooled fcilities include the numbers of registered community phrmcies nd public clinics in Dt source: SAPC register on 21 November Popultion dt re mid-yer estimtes for Number of public clinics sourced from Ntionl Audit of Helth Fcilities, South Africn benchmrk. 18 of community phrmcies. Six of the respondents criticized the government s filure to improve rurl phrmceuticl services, evidenced by lck of incentives to open community phrmcies, especilly independent phrmcies, in these res. One interviewee suggested Reserch tht the government could esily provide incentives, such s miniml rent in government building or to contrct services to privte community phrmcies gurnteeing certin income nd with priority for contrct renewl. Another respondent mentioned tht yers bck phrmcies opened in rurl res becuse the incentive ws tht they would get ll district surgeons prescriptions. Tht ws government policy but it ws tken wy just like tht, without ny considertion for these phrmcies nd how they would survive. Most of these phrmcies then pplied for section 22 A (15) permit to survive in these res [ ] nd they ply mssive role in providing these services. According to representtive from leding corportion, problem for the compny s future expnsion into townships nd rurl res is the conflict between profitbility nd the provision of phrmceuticl cre. Respondents held strong opinions bout the pprent lck of enforcement of regultions on entry to the mrket. More thn 50% (5/9) of interviewees were convinced tht licences cn be cquired through illegl mens nd few questioned the uthenticity of the deprtment of helth s licensing records. The mjority of stkeholders criticized the licensing criteri for opening new community phrmcy in shopping mlls (i.e. mximum of one community phrmcy per visitors to the mll per month nd not within 500 m rdius of n existing community phrmcy. One respondent expressed the view tht licensing hs become brrier The Deprtment of Helth is not pplying it like it should. Phrmcies should be sited, tking into ccount the helth cre needs, income groups, size of popultion nd wht is required to mke phrmcy vible. Most respondents felt tht pricing regultions hve given compnies (corporte nd courier phrmcies) competitive dvntge over independent community phrmcies, mny of which hve closed down s result. In ddition, corporte businesses re ble to hve phrmcies within stores, which mke it possible for phrmcy dispensries to survive even if they mke no profits. Five of the nine respondents identified the inbility to finnce n independent phrmcy s n importnt brrier to the growth nd expnsion of the phrmcy sector. One interviewee Bull World Helth Orgn 2014;92: doi: 485

5 Reserch Kim Wrd et l. mentioned tht phrmcy is no longer seen s n investment; it is very difficult to sell your phrmcy when you retire There is no outside funding for new phrmcists to open phrmcies In the pst, the wholeslers would help to negotite with bnks nd provide surety. The condition ws tht the phrmcy would use this wholesler for purchses; t the time wholesling ws more profitble, but now it s not profitble t ll. All but one interviewee gve one or more resons for considering it vitl to support the independent community phrmcy mrket. Such resons included independent community phrmcies presence in high-, middle- nd low-income res; their willingness to serve ll demogrphic groups nd their dediction to the type of bsic helth services required in poorer res. When sked bout chllenges beyond regultory reform, ll respondents nswered tht humn resource shortges re mjor thret to community phrmcy growth. A respondent from corporte community phrmcy put it this wy: The biggest chllenge for us is obviously the vilbility of phrmcists nd the vilbility of phrmcy support stff. Discussion Our study shows tht monitoring trends in the distribution of community phrmcies is fesible nd cn be ccomplished by combining key vribles from the deprtment of helth licensing nd SAPC registrtion dtbses, despite concerns bout the qulity of the dt from these sources. The increse in the number of community phrmcies hs not kept pce with popultion growth nd there re differences between urbn nd rurl provinces nd between the most nd lest deprived districts. Although corportions hve seen substntil growth, this hs not resulted in improved density rtios or equity in distribution. Our empiricl dt re supported by the perceptions of key members of the phrmcy sector. Ten yers fter deregultion opened the mrket to corporte businesses, community phrmcies in South Afric continue to be concentrted in urbn provinces. 8 Our study is the first to demonstrte tht even lrger differences exist mong districts thn mong provinces nd tht the lest deprived districts hve the highest community phrmcy densities. This shows tht the helth-cre system hs become more mrket oriented, with the result tht res with lesser need s function of popultion size hve greter ccess to medicl cre, phenomenon known s Hrt s inverse cre lw. 24 Wht this ultimtely demonstrtes is the filure of South Afric s neo-liberl policies to reverse inequities by expnding the privte community phrmcy sector, despite legl restrictions for entering the mrket bsed on popultion size. 1 A Europen report bsed predominntly on qulittive dt showed similr urbn clustering following deregultion of the community phrmcy sector in countries such s Englnd, Irelnd nd Norwy. However, country-specific pproches, such s cluses or greements with compnies gurnteeing continued services in rurl res, improved ccess to community phrmcies. 25 In Englnd, the implementtion of mrket entry regultions reduced inequities in the geogrphicl distribution of community phrmcies. 26 The decline of new independentlyowned community phrmcies is worrisome from the perspective of ccess to community phrmcies, prticulrly since these phrmcies re more likely to be estblished close to poor communities thn corporte businesses. Corporte community phrmcies hve gined competitive edge over independent community phrmcies by reducing their opertionl costs nd improving efficiencies in their supply chin through verticl integrtion. This llows them to sell medicines well below the mximum price stipulted in pricing regultions. 11 As such, they rely on low price, highvolume business model nd incresed profits from other product lines in their stores to compenste for low profit mrgins from the dispensry. Contrcting with the ntionl helth insurnce could provide lifeline for the independent community phrmcy industry. In light of post-prtheid urbniztion nd of the filure of community phrmcy nd clinic density to keep pce with popultion growth, the most expedient nd short-term pproch to improving the geogrphicl distribution of phrmceuticl services my be to combine these fcilities. However, this will not necessrily improve service vilbility becuse services might still be insufficient, especilly in the public sector. A recent ntionwide udit of public sector primry helth cre fcilities reveled poor cpcity nd medicine vilbility in mny rurl res. 27 Attention to such deficits is needed in plns to revitlize the country s primry helth cre. 7 Besides expertise nd efficiencies in drug supply mngement, community phrmcies offer n opportunity to deliver expnded primry helth cre services through the reinsttement of section 22 A (15) permits nd support for the proposed uthorized phrmcist prescriber qulifiction, which llows phrmcists to dignose nd prescribe from the primry helth cre essentil medicines list nd the stndrd tretment guidelines. 28 Both re currently being reviewed by the deprtment of helth. The key informnts of this study corroborted the findings from 1998 tht in rurl res holding section 22 A (15) licences, community phrmcy utiliztion rtes were high, especilly mong the poor. 12 With legisltive support, this model could be dopted by ll community phrmcies contrcting under the ntionl helth insurnce scheme to improve ccess not only to phrmceuticl services, but lso to defined pckge of primry helth cre services in urbn nd rurl res. The model could be piloted in one or more of the rurl pilot districts where existing permit holders prctise. This is in line with recommendtions from countries with policy of universl helth coverge to pilot nd pln interventions in underserved res first. 29 Conclusion To improve the geogrphicl distribution of community phrmcies, it will be necessry to urgently review licensing criteri nd rurl incentives to ensure tht rurl prts of the country nd deprived res ttin the service density levels tht exist in urbn zones nd in the lest deprived res. Furthermore, expnding service vilbility, in the event tht services re combined, will require urgent ction by the deprtment of helth to lift the suspension of section 22 A (15) permits. The deprtment of helth will lso need to tke ction with respect to the ntionl phrmcy workforce. In prticulr, strtegies re needed to increse the number of phrmcy nd phrmcy technicin students in universities. 6 Finlly, routine indictors, such s the number of community phrmcies nd public clinics per Bull World Helth Orgn 2014;92: doi:

6 Kim Wrd et l. Reserch residents t the district level, should be published nnully in the district helth brometer to monitor strides towrds chieving equity in the distribution of phrmcy services. Acknowledgements We thnk our prtners t the Swiss Tropicl nd Public Helth Institute, University of Bsel, Switzerlnd; the University of Edinburgh, United Kingdom of Gret Britin nd Northern Irelnd; the University of Ghent, Belgium; Mkerere University, Ugnd; Mbrr University of Science nd Technology, Ugnd; the University of the Western Cpe, South Afric, nd the Foundtion for Reserch in community Helth, Indi. Funding: This reserch ws supported by the Europen Union Seventh Frmework Progrmme Theme: Helth (Grnt no ) under the title Access to Medicines in Afric nd South Asi. Competing interests: None declred. ملخص تقييم اإلنصاف يف التوزيع اجلغرايف للصيدليات املجتمعية يف جنوب أفريقيا يف إطار التحضري لنظام التأمني الصحي الوطني الغرض حتري اإلنصاف يف التوزيع اجلغرايف للصيدليات املجتمعية يف جنوب أفريقيا وتقييم ما إذا كانت اإلصالحات التنظيمية قد أدت إىل تعزيز هذا اإلنصاف. الطريقة تم استخدام البيانات حول الصيدليات املجتمعية التي تم احلصول عليها من إدارة الصحة الوطنية وجملس صيادلة جنوب أفريقيا بغية حتليل التغري يف ملكية الصيدليات املجتمعية وكثافتها )العدد لكل نسمة( يف الفرتة ما بني عامي 1994 إىل 2012 يف كل املقاطعات التسع واملناطق اخلمس عرشة املختارة. باإلضافة إىل ذلك تم حساب كثافة العيادات العامة وحدها ومع الصيدليات املجتمعية ومقارنتها بأساس مرجعي وطني لعيادة واحدة لكل نسمة. وأجريت املقابالت مع تسعة خرباء وطنيني من قطاع الصيدلة. النتائج ازداد عدد الصيدليات املجتمعية بنسبة % 13 بني عامي 1994 إىل بمعدل أقل من نمو السكان الذي بلغت نسبته %. 25 ويف عام 2012 كانت الصيدليات املجتمعية أعىل يف املقاطعات احلرضية وكانت أعىل ثامنية مرات يف املناطق األقل حرمانا عنها يف املناطق األكثر حرمانا. واستمر سوء التوزيع رغم النمو يف الصيدليات املجتمعية املؤسسية. ويف عام 2012 حققت مقاطعتان فقط األساس املرجعي عيادة واحدة لكل نسمة رغم حتقيق مجيع املقاطعات هلذا األساس املرجعي عند ضم الصيدليات املجتمعية والعيادات. وأعرب اخلرباء عن خماوفهم من أن يؤدي نقص احلوافز الريفية ومعايري الرتخيص غري املالئمة ونقص العاملني يف القطاع الصيديل إىل تقويض الوصول إىل اخلدمات الصيدالنية ال سيام يف املناطق الريفية. االستنتاج للحد من عدم اإلنصاف يف توزيع اخلدمات الصيدالنية يتعني وضع سياسات وترشيعات جديدة لزيادة التوظيف ووجود الصيدليات. 摘 要 评 估 南 非 社 区 药 房 地 理 分 布 的 均 衡 性 为 发 展 全 民 健 康 保 险 计 划 作 准 备 目 的 探 讨 南 非 社 区 药 房 的 地 理 分 布 的 均 衡 性, 并 评 估 程 度 高 的 省 份 社 区 药 房 密 度 较 高, 条 件 最 好 的 地 区 比 监 管 改 革 是 否 促 进 这 样 的 均 衡 性 最 缺 医 少 药 的 地 区 的 药 房 密 度 高 八 倍 尽 管 企 业 社 区 方 法 使 用 国 家 卫 生 部 和 南 非 药 剂 师 协 会 有 关 社 区 药 房 药 店 增 加, 但 是 依 然 存 在 分 布 不 均 在 2012 年, 尽 管 的 数 据 分 析 1994 年 和 2012 年 之 间 在 所 有 9 个 省 和 15 社 区 药 房 和 诊 所 加 在 一 起 所 有 省 份 都 达 到 每 万 人 口 一 个 选 定 的 地 区 中 社 区 药 店 所 有 权 和 密 度 的 变 化 ( 每 万 所, 但 是 仅 有 两 省 达 到 每 万 人 口 一 个 药 房 的 基 准 专 名 居 民 的 数 量 ) 此 外, 计 算 公 立 诊 所 ( 单 独 计 算 或 加 家 们 表 达 了 对 农 村 激 励 缺 失 许 可 标 准 不 当 及 药 房 工 上 社 区 药 房 ) 的 密 度, 并 与 每 万 名 居 民 一 个 诊 所 的 国 作 人 员 短 缺 可 能 会 阻 碍 人 们 获 得 优 质 服 务 的 忧 虑, 在 家 基 准 进 行 比 较 面 访 了 药 事 领 域 的 九 位 国 内 专 家 农 村 地 区 尤 其 如 此 结 果 在 1994 年 到 2012 年 间, 社 区 药 房 数 量 增 加 结 论 要 减 少 药 事 服 务 分 布 的 不 均 衡, 需 要 新 政 策 和 立 13% 低 于 25% 的 人 口 增 长 率 在 2012 年, 城 镇 化 法 来 增 加 人 员 配 备 和 药 房 数 Résumé Évlution de l équité dns l distribution géogrphique des phrmcies communutires en Afrique du Sud en préprtion d un régime ntionl d ssurnce mldie Objectif Étudier l équité dns l distribution géogrphique des publiques, seules et vec les phrmcies communutires, été clculée phrmcies communutires en Afrique du Sud et évluer si les réformes et comprée à une référence ntionle d une (1) clinique pour de l réglementtion ont promu cette équité. hbitnts. Des entretiens ont été menés vec neuf experts ntionux Méthodes Les données sur les phrmcies communutires provennt du secteur phrmceutique. du ministère ntionl de l snté et de l ordre des phrmciens en Résultts Le nombre de phrmcies communutires ugmenté Afrique du Sud ont été utilisées pour nlyser les vritions en mtière de de 13% entre 1994 et 2012 inférieur à l croissnce de l popultion propriété et de densité (nombre pour hbitnts) des phrmcies de 25%. En 2012, l densité des phrmcies communutires étit communutires entre 1994 et 2012 dns l ensemble des 9 provinces supérieure dns les provinces urbines et étit 8 fois plus élevée dns les et dns 15 districts sélectionnés. En outre, l densité des cliniques qurtiers les moins défvorisés que dns les qurtiers les plus défvorisés. Bull World Helth Orgn 2014;92: doi: 487

7 Reserch L muvise distribution persisté mlgré l croissnce des groupes de phrmcies communutires. En 2012, seules 2 provinces ont tteint le tux de référence de 1 pour hbitnts, bien que toutes les provinces ient rélisé cet objectif lorsque les phrmcies et les cliniques ont été combinées. Les experts crignent que l bsence d incittions rurles, les critères inppropriés d octroi de licence et une pénurie de Kim Wrd et l. personnel qulifié dns les phrmcies puissent nuire à l ccès à des services phrmceutiques, en prticulier dns les zones rurles. Conclusion Pour réduire les iniquités dns l distribution des services phrmceutiques, de nouvelles politiques et législtions sont nécessires pour ugmenter les effectifs et l présence des phrmcies Резюме Оценка равномерности географического распределения аптек в сельских общинах Южной Африки в рамках подготовки к национальной системе медицинского страхования Цель Исследовать равномерность географического распределения аптек в сельских общинах Южной Африки и оценить, способствовали ли законодательные реформы достижению такой равномерности. Методы Для анализа изменений в структуре владения и плотности распределения аптек (количество аптек на жителей) были использованы данные по общинным аптекам из Национального департамента здравоохранения и Совета по фармацевтической практике ЮАР за период между 1994 и 2012 годами по всем 9 провинциям и 15 выбранным районам. Кроме того, рассчитывалась плотность распределения государственных клиник как отдельно, так и совместно с общинными аптеками, и сравнивалась с национальным эталоном одна клиника на жителей. У девяти национальных экспертов из аптечной отрасли были взяты интервью. Результаты Количество аптек в сельских общинах выросло на 13% за период между 1994 и 2012 гг. что меньше, чем рост населения (25%). В 2012 году плотность аптек в сельских общинах была выше, чем в городских провинциях, и была в восемь раз выше в наиболее экономически развитых районах по сравнению с наиболее обездоленными областями. Неравномерность распределения сохранялась, несмотря на рост числа аптек в корпоративных сообществах. В 2012 году только две провинции удовлетворяли эталонному показателю наличия одной клиники на населения, хотя все провинции достигали его при объединении количества клиник и общинных аптек. Эксперты выразили озабоченность тем, что отсутствие стимулов для развития сети аптек в сельской местности, неадекватные критерии лицензирования и нехватка аптечных работников могут затруднить доступ населения к фармацевтическым услугам, особенно в сельских районах. Вывод Для уменьшения неравенства в распределении фармацевтических услуг необходимы новые стратегии и законы, позволяющие увеличить количество аптек и их персонала. Resumen L evlución de l equidd en l distribución geográfic de ls frmcis comunitris en Sudáfric pr preprr un pln de seguro médico ncionl Objetivo Investigr l equidd en l distribución geográfic de ls en ls provincis urbns, y er ocho veces myor en los distritos menos frmcis comunitris en Sudáfric y evlur si los cmbios legisltivos desfvorecidos que en los más desfvorecidos. L ml distribución hn promovido dich equidd. persistió pesr del crecimiento de ls frmcis comunitris colectivs. Métodos Se utilizron dtos sobre ls frmcis comunitris del En 2012, solo dos provincis cumplieron el punto de referenci de un deprtmento ncionl de slud y del consejo frmcéutico de Sudáfric frmci por cd hbitntes pesr de que tods ls provincis pr nlizr el cmbio en l propiedd y l densidd de ls frmcis lo logrron cundo se combinron ls frmcis comunitris con ls comunitris (número por cd hbitntes) entre 1994 y 2012 clínics. Los expertos expresron su preocupción y que l flt de en ls nueve provincis y los 15 distritos selecciondos. Además, se incentivos rurles, los criterios indecudos pr l concesión de licencis clculó y compró l densidd de ls clínics públics, por seprdo y y l escsez de trbjdores frmcéuticos podrín debilitr el cceso con frmcis comunitris, con un punto de referenci ncionl de un servicios frmcéuticos, especilmente en ls zons rurles. clínic por cd hbitntes, y se entrevistron nueve expertos Conclusión Con objeto de reducir l desiguldd en l distribución de ncionles del sector frmcéutico. los servicios frmcéuticos, es necesrio desrrollr un legislción y Resultdos El número de frmcis comunitris umentó en un 13 % polítics nuevs pr umentr l dotción de personl y l presenci entre 1994 y un crecimiento inferior l de l poblción, que fue de ls frmcis. del 25 %. En 2012, l densidd de ls frmcis comunitris er más lt References 1. Atgub JE, Akzili J, McIntyre D. Socioeconomic-relted helth inequlity in South Afric: evidence from generl household surveys. Int J Equity Helth. 2011;10(1):48. doi: 2. Atgub JE, McIntyre D. Who benefits from helth services in South Afric? Helth Econ Policy Lw. 2013;8(1): doi: S Coovdi H, Jewkes R, Brron P, Snders D, McIntyre D. The helth nd helth system of South Afric: historicl roots of current public helth chllenges. Lncet. 2009;1(9692): doi: S (09)60951-X 4. Gilson L, McIntyre D. Post-prtheid chllenges: household ccess nd use of helth cre in South Afric. Int J Helth Serv. 2007;37(4): doi: PMID: Humn resources for helth, South Afric. HRH strtegy for the helth sector: 2012/ /17. Arcdi: Deprtment of Helth South Afric; Phrmcy humn resources in South Afric [Internet]. Pretori: South Africn Phrmcy Council; Avilble from: emgs/phrs/pgeflip.html [cited 2012 Feb 21]. 7. Ntionl Helth Insurnce in South Afric (Green Pper). Pretori: Deprtment of Helth South Afric; Avilble from: org.z/sites/defult/files/2bcce61d2d1b8d972f41b0e2c84b.pdf [cited 2014 Feb 21]. 488 Bull World Helth Orgn 2014;92: doi:

8 Kim Wrd et l. Reserch 8. Gilbert L. Your helth is our duty, our commitment, our life s work: phrmcists in South Afric clim new ground. Soc Trnsit. 2004;35(2): doi: 9. Ntionl drug policy for South Afric. Pretori: Deprtment of Helth South Afric; Avilble from: s17744en/s17744en.pdf [cited 2014 Feb 21]. 10. Phrmcy Act of 1974 (Act no. 53 of 1974). Pretori, South Afric. 11. Medicines nd relted substnces control Act of 1965 (Act no. 101 of 1965). Pretori, South Afric. 12. Gilbert L. Phrmcy s ttempts to extend its roles: cse study in South Afric. Soc Sci Med. 1998;47(2): doi: S (98) Gilbert L. Interprofessionl cre in South Afric: the expnding role of community phrmcy nd the therpeutic llince with nurses. J Interprof Cre. 1999;13(2): doi: org/ / Western Cpe Government [Internet]. Cpe Town: Western Cpe Government; c2014: Agreement between the Helth Deprtment nd Clicks Set to improve ccess to helth cre [bout 1 screen]. Avilble from: [cited 2014 Feb 21]. 15. Monitoring equity in ccess to AIDS tretment progrmmes: review of concepts, models, methods nd indictors. Genev: World Helth Orgniztion; Brvemn PA. Monitoring equity in helth nd helthcre: conceptul frmework. J Helth Popul Nutr. 2003;21(3): Dy C, Brron P, Mssyn N, Pdrth A, English R, editors. District Helth Brometer Yer 2010/11. Durbn: Helth Systems Trust; Ntionl Deprtment of Helth Strtegic Pln 2010/ /13. Pretori: Ntionl Deprtment of Helth; Avilble from ntionlplnningcycles.org/sites/defult/files/country_docs/south%20afric/ south_fric_strtegic_helth_pln_ pdf [cited 2014 My 05]. 19. Gilbert L. community phrmcy in South Afric: chnging profession in society in trnsition. Helth Plce. 1998;4(3): doi: org/ /s (98) Annul helth sttistics Pretori: Ntionl Deprtment of Helth; Helth System Trust [Internet]. Durbn: Helth System Trust; Popultion estimtes: NDOH/HISP popultion estimtes [bout 2 screens]. Avilble from: Popultion /ZA_PopEst_2001_2016_With_PopPyrmids_Feb_2010.7z [cited 2014 Feb 21]. 22. Mid-yer popultion estimtes, Pretori: Sttistics South Afric; Avilble from pdf [cited 2014 Feb 21]. 23. Census 2001: Investigtions into pproprite definitions of urbn nd rurl res for South Afric. Pretori: Sttistics South Afric; Hrt JT. The inverse cre lw. Lncet. 1971;1(7696): doi: dx.doi.org/ /s (71)92410-x 25. Vogler S, Arts D, Sndberger K. Impct of phrmcy deregultion nd regultion in Europen countries. Vienn: Gesundheidt Osterreich GmbH; Felix J. Inequlity in the provision of community phrmceuticl services in Englnd [disserttion]. York: Centre for Helth Economics, University of York; Deprtment of Helth, South Afric. The ntionl helth cre fcilities bseline udit ntionl summry report. Westville: Helth System Trust; South Africn Phrmcy Council. Scope of prctice nd qulifiction for uthorised phrmcist prescriber (34428). Pretori: Government Gzette; The world helth report 2008 primry helth cre: now more thn ever. Genev: World Helth Orgniztion; Bull World Helth Orgn 2014;92: doi: 489

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