Assessing equity in the distribution of community pharmacies in South Africa in preparation for the National Health Insurance scheme

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1 Assessing equity in the distribution of community pharmacies in South Africa in preparation for the National Health Insurance scheme Ward KL, Sanders D, Leng HMJ and Pollock, A

2 OUTLINE Introduction Methods Results Discussion Conclusion

3 INTRODUCTION (I) South Africa s health and healthcare inequities are well documented. 1-4 Historically, pharmaceutical services were concentrated in urban areas. 5 Private community pharmacies are classified as corporates or independently-owned Corporates (owned by large public or private companies) Independently-owned (owned and managed by one or more pharmacists) Post-1994 regulatory reform in South Africa (SA) aimed to reverse these inequities through inter alia, Section 22 A (15) permits for rural pharmacies (suspended since 1998) Lay-ownership of community pharmacies allowing corporates to enter market Licencing regulations restricting location of new community pharmacies 6-8

4 INTRODUCTION (II) Table 1: National Department of Health (NDOH) criteria for establishing need for pharmaceutical services Item Criteria Pharmacies per 10,000 residents 2:10,000 with exceptions (e.g. shopping malls, rural areas) Proximity to other pharmacies 500m with exceptions (e.g. deep rural areas) Proximity to other medical services Consider doctors in area; 500m (±40 patients/ day) with exceptions (e.g. deep rural areas)

5 INTRODUCTION (III) The Green Paper for a National Health Insurance (NHI) identifies private community pharmacies as additional access points for medicines in combination with public clinics. 9 Will the inclusion of community pharmacies as additional medicine collection points under the NHI promote equitable distribution of pharmaceutical services?

6 INTRODUCTION (IV) AIM To examine the changes in ownership and geographical distribution of CPs relative to regulatory reform from the perspective of equity. OBJECTIVES Assess number of community pharmacies per 10,000 residents at provincial and selected district level Interview key informants about their perceptions surrounding the impact of regulatory reform on the distribution of community pharmacies We summed community pharmacies and public clinics to assess their combined provincial distribution patterns against a SA benchmark

7 METHODS I Data sources CP licence data: NDOH, licencing unit CP registration data : current SAPC register, literature for 1994 data 10 Public clinic data: National audit of health facilities 11 Population data: Statistics, SA and NDOH/HISP 12,13

8 METHODS II Data analysis Density: Number of facilities per 10,000 residents Comparison of numbers, ownership and densities of community pharmacies at provincial level Community pharmacies mapped and counted for 15 districts (five districts each from lowest, highest and middle quintile deprivation indices according to District Health Barometer) and densities for CPs plotted against deprivation index

9 METHODS III Data analysis cont. Summed public clinics and community pharmacies to assess combined densities against benchmark of 1 clinic per 10,000 residents

10 METHODS IV Pharmacy expert interviews 9 experts on pharmacy regulation were purposively selected Section 22(15) licence holders (Also represent pharmacy at provincial and national levels) (N=2) Supermarket Chains (Directors of professional services for major) (N=2) Unstructured interviews to elicit participant views on the impact of regulatory reform on access to medicines & equity in such access. Independent Community Pharmacy Association (Chairperson) (N=1) Pharmaceutical Society of South Africa (Branch directors, past presidents) (N=4) Data coded in MAXQDA and themes identified from data by research team

11 RESULTS I Data limitations (i) NDOH licence database May 2003 December 2012 Discrepancies between licences issued and new CP registrations Limited to using licence application data ( ) for ownership trend analysis

12 RESULTS II Data limitations (ii) SAPC Register Jan 1994 December 2012 Lack historical disaggregated data Limited to using current registration data for district mapping (November 2012) No ownership information

13 RESULTS III Fig. 1: Annual numbers of CP license applications made to the NDOH between 2008 and by ownership category (N=1124) Number of licence applications unknown Year Companies Independents (Close corporations, partnerships, sole proprietors)

14 RESULTS IV Table 2: Provincial variation in CP registrations, growth and ratios per 10,000 residents against population growth in 1994 and 2012 Province (ranked from m o s t t o l e a s t rural) Number of registered community pharmacies % CP growth to 2012 % population growth 1994 to 2012 CPs per 10,000 residents Limpopo Eastern Cape Mpumalanga North West Kwazulunatal Free State Northern Cape Western Cape Gauteng Country

15 RESULTS V Fig. 2: Ratios of CPs per population relative to deprivation index in 15 selected districts for 2012

16 RESULTS VI Fig. 3: Ratios of CPs, public clinics and pooled facilities per 10,000 residents in SA provinces against SA benchmark for public clinics in Public Clinics CPs Pooled facilities SA benchmark

17 RESULTS VII Diagram 1: Key informant perceptions surrounding regulation Inappropriate Licencing Criteria Poor Enforcement Of Licencing Regulations Regulation has failed to improve the distribution of community pharmacies Lack Of Rural Incentives Closing down of many independently owned pharmacies

18 RESULTS VIII Diagram 2: Key informant perceptions surrounding threats to growth in community pharmacy sector Lack of financing Pricing regulations Human Resource Shortages

19 DISCUSSION I Monitoring ownership and distribution trends of community pharmacies is possible when combining key variables from NDOH and SAPC databases. Distribution remains inequitable (favouring urban provinces) in 2012 despite regulatory changes and empirical data is supported by perceptions of key members of pharmacy sector. At district level, these disparities are even greater and illustrate the Inverse Care Law, i.e. least deprived districts have greater access to community pharmacies

20 DISCUSSION II Combining public clinics and CPs improved densities, although services might still be insufficient, especially in public sector (poor capacity and medicine availability in many public rural clinics). Pharmacy workforce shortages presents another challenge to both sectors. Community pharmacies offer expertise and efficiencies in drug supply management and could potentially offer expanded primary health care services under the NHI through reinstatement of section 22 A(15) permits.

21 CONCLUSION & RECOMMENDATIONS To reduce inequity in the distribution of pharmaceutical services, new policies and legislation are needed to increase staffing and the presence of pharmacies. NDOH needs to urgently review licencing criteria and rural incentives Lift suspension of section 22 A(15) licences to expand service availability Strategies needed to increase number of pharmacy and pharmacy technician students at universities. Indicators (e.g. density of pharmaceutical services) should be monitored at district level

22 References 1. Ataguba JE, Akazili J, McIntyre D. Socioeconomic-related health inequality in South Africa: evidence from general household surveys. Int J Equity Health. 2011;10(1):48. doi: 2. Ataguba JE, McIntyre D. Who benefits from health services in South Africa? Health Econ Policy Law. 2013;8(1): doi: 3. Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009;1(9692): doi: 4. Gilson L, McIntyre D. Post-apartheid challenges: household access and use of health care in South Africa. Int J Health Serv. 2007;37(4): doi: HS.37.4.f PMID: Gilbert L. Your health is our duty, our commitment, our life s work: pharmacists in South Africa claim new ground. Soc Transit. 2004;35(2): doi: 6. National drug policy for South Africa. Pretoria: Department of Health South Africa; Available from: [cited 2014 Feb 21]. 7. Pharmacy Act of 1974 (Act no. 53 of 1974). Pretoria, South Africa.

23 References 8. Medicines and related substances control Act of 1965 (Act no. 101 of 1965). Pretoria, South Africa. 9. National Health Insurance in South Africa (Green Paper). Pretoria: Department of Health South Africa; Available from: 2bcce61d2d1b8d972af41ab0e2c8a4ab.pdf [cited 2014 Feb 21]. 10. Gilbert L. community pharmacy in South Africa: a changing profession in a society in transition. Health Place. 1998;4(3): doi: S (98) Annual health statistics Pretoria: National Department of Health; Health System Trust [Internet]. Durban: Health System Trust; Population estimates: NDOH/HISP population estimates [about 2 screens]. Available from: / ZA_PopEst_2001_2016_With_PopPyramids_Feb_2010.7z [cited 2014 Feb 21]. 13. Mid-year population estimates, Pretoria: Statistics South Africa; Available from [cited 2014 Feb 21].

24 Acknowledgements This paper results from research funded by the European Union Seventh Framework Programme Theme: Health (Grant no ) under the title 'Access to Medicines in Africa and South Asia [AMASA]'. The project team includes partners at the Swiss Tropical and Public Health Institute at the University of Basel (Switzerland), University of Edinburgh (UK), University of Ghent (Belgium), Queen Mary University of London, Makerere University (Uganda) Mbarara University of Science and Technology (Uganda), University of the Western Cape (South Africa), and the Foundation for Research in Community Health (India).

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