Impact of Supply Chain Disruptions on the Availability and Affordability of Essential Medicines at Kenema Pharmacies in Addis Ababa, Ethiopia

Impact of Supply Chain Disruptions on the Availability and Affordability of Essential Medicines at Kenema Pharmacies in Addis Ababa, Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Supply Chain Disruptions on the Availability and Affordability of Essential Medicines at Kenema Pharmacies in Addis Ababa, Ethiopia Nurredin Shiferaw, Hadas Zeru, Fenan Aklilu, Fakiha Ali, Habtamu Solomon Mengistu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9328438/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Introduction : Supply chain disruptions critically threaten essential medicine access in low- and middle-income countries like Ethiopia. Kenema Pharmacies, a public-sector initiative in Addis Ababa, was established to improve equitable access, yet its effectiveness amid systemic disruptions remains understudied. This study aimed to assess the impact of these disruptions on medicine availability and affordability at Kenema Pharmacies in Lideta Sub-City. Method : A mixed-methods cross-sectional design was employed. Quantitative data were collected via structured questionnaires from 257 pharmacy clients, selected through systematic random sampling. Qualitative insights were gathered through semi-structured interviews with 12 key stakeholders. Results: Over half (57.6%) of clients faced difficulties obtaining prescribed medicines, with frequent stockouts of antibiotics, insulin, and medications for chronic diseases. Affordability was the predominant barrier, with 53.3% rating medicines as unaffordable and 51% forgoing purchases due to cost. Despite adequate physical access, supply volatility and financial constraints undermined effective utilization. Upstream procurement and distribution inefficiencies directly compromise the pharmacy’s operational performance. Supply chain disruptions at Kenema Pharmacies in Lideta Sub-City hindered access to essential medicines by causing frequent stockouts and high costs. Conclusion : While Kenema Pharmacies improve geographic access, their role in ensuring reliable and affordable medicine supply is severely limited by national supply chain weaknesses. Strengthening procurement systems, inventory management, and financial protection mechanisms is essential for achieving equitable access to essential medicines in urban Ethiopia. availability affordability supply chain disruption inventory management Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Health was widely recognized as a fundamental human right, and ensuring equitable access to essential medicines (EMs) was a cornerstone of that principle [ 1 ]. Essential medicines are those that address the priority healthcare needs of a population, selected with regard to disease prevalence, evidence on efficacy, and comparative cost-effectiveness [ 2 ]. In Ethiopia, the Ethiopian Pharmaceutical Supply Agency (EPSA) played a central role in the procurement, storage, and distribution of these medicines. However, EPSA struggled with persistent challenges like inaccurate forecasting, long procurement cycles, and data coordination issues [ 3 ]. These supply chain disruptions often resulted in stock-outs, medicine wastage, and treatment delays, which exacerbated health inequities and hindered progress toward Sustainable Development Goal three [ 4 ]. Global crises like the COVID-19 pandemic further worsened these disruptions, especially in rural and underserved areas. As part of the government’s effort to ensure access to medication, Kenema Pharmacies Partnership (KPP) operated as a government-owned public retail pharmacy chain established under the Addis Ababa City Administration. The enterprise was founded to improve equitable access to essential medicines and to offer more affordable pharmaceutical services for residents of Addis Ababa and surrounding areas. According to a case study of KPP, the mission statement explicitly included providing “life-saving medicines at an affordable price” and supplying required drugs in type and quantity for the wellbeing of the community [ 5 ]. As such, KPP represented the government’s strategic intervention to counteract common market failures in medicine accessibility, especially in urban low-income settings where private retail pharmacies often operated at higher price points or faced supply constraints. This study focused on evaluating the Kenema Pharmacies chains in the Lideta Sub-City of Addis Ababa as a representative case to highlight the broader national impacts of challenges to affordable access to medication. By providing evidence-based insights, it aimed to inform policy reforms that could strengthen the resilience of Ethiopia’s medicine supply chain. Kenema Pharmacies operated a network of retail pharmacies throughout Addis Ababa, focusing on affordability and equitable access, particularly for low-income populations that were typically underserved by private pharmacies [ 5 , 6 ]. Through this model, the government sought to bridge the gap left by inefficiencies in the private sector and EPSA’s centralized supply chain, which was often strained due to funding shortages, logistical delays, and procurement bottlenecks. Although disaggregated performance data specifically for individual Kenema Pharmacies branches was not available, the general picture of essential medicine availability and affordability in Addis Ababa remained concerning. A recent study on generic cardiovascular medicines found that the availability of lowest-priced generics (LPGs) was only 34.52%, with public sector availability at 33.73% and private pharmacies at 29.8% [ 6 ]. Similarly, a cross-sectional study on psychotropic medicines revealed that the mean availability of LPGs in Addis Ababa was 24.33%, with standard treatment costs ranging from 0.1 to 7.8 days’ wages in the public sector and 0.8 to 25 days’ wages in the private sector [ 4 , 7 ]. These findings pointed to serious challenges not only in stock availability but also in affordability, with high prices making treatments inaccessible for most wage-earning patients. These issues disproportionately affected vulnerable populations, especially those living in urban low-income settings such as Lideta Sub city. Without access to essential medications, these populations faced an increased risk of disease progression, preventable complications, and high health expenditures. Additionally, the lack of reliable access to affordable medication could lead to reduced trust in the public health system and increased reliance on informal or unregulated medicine sources. Despite these challenges, there was limited empirical research assessing the effectiveness of public pharmacies like KPP in mitigating the effects of supply chain disruptions and providing affordable, quality-assured medicines [ 7 ]. Access to essential medicines is a critical determinant of health outcomes globally. Numerous studies have established that when populations have reliable access to affordable medicines, there are significant improvements in overall public health indicators, including reduced morbidity and mortality rates [ 8 ]. A meta-analysis by Cameron found that the availability of medicines in low- and middle-income countries ranges from as low as 24% to as high as 80%, with public sector availability typically on the lower end of that spectrum [ 9 ]. In Ethiopia, the challenge of medicine availability and affordability is compounded by economic constraints, logistical issues, and infrastructural limitations [ 10 ]. A study by Abdu highlighted that about 47-63.9% of essential medicines are unaffordable for the average Ethiopian household, particularly impacting rural communities and those working in informal sectors [ 11 ]. The literature also points to several deeper factors influencing medicine access. These include policy and regulatory environments, the efficiency of national procurement and distribution systems, and the role of international donor support [ 12 ]. For instance, Wirtz note that countries with strong regulatory frameworks and robust supply chain governance tend to perform better in ensuring continuous availability of essential medicines [ 10 ]. In the Ethiopian context, the role of the Ethiopian Pharmaceutical Supply Agency (EPSA) is pivotal. While EPSA has made strides in improving the supply chain, challenges remain in terms of forecasting accuracy, timely procurement, and distribution logistics [ 3 ]. These systemic issues are further influenced by global supply chain disruptions, such as those seen during the COVID-19 pandemic, which have underscored the need for more resilient and adaptive supply chain mechanisms [ 13 ]. Robust policy and regulatory environments are critical for ensuring sustainable access to medicines. Countries with strong governance structures and transparent regulatory systems tend to perform better in maintaining consistent medicine availability [ 10 ]. In Ethiopia, ongoing health system reforms, including the expansion of health insurance and public pharmacy networks, represent key policy initiatives aimed at improving access. The establishment of KPP signifies a strategic public‑sector intervention by the Addis Ababa City Administration to enhance access to essential medicines by expanding government‑owned retail pharmacy services in urban Ethiopia [ 5 ]. According to a case study, KPP currently operates 43 branches within Addis Ababa and serves a wide customer base, yet the research indicates that this branch network remains insufficient to meet city‑wide demand. The study revealed that weekly average customer numbers for KPP branches ranged from 587 to 1,848 depending on pharmacy class, and that the average dispensing time was only 1.6 minutes suggesting high workload and potential constraints on service quality. Given the broader national evidence of medicine availability and affordability challenges, the role of KPP deserves close evaluation. For example, studies in Addis Ababa demonstrate that availability of lowest priced generics (LPGs) for cardiovascular disease medicines was only 34.52% overall, with public sector availability at 33.73% [ 6 ], and that psychotropic LPGs had a mean availability of 24.33%, with private‑sector access costs reaching 25 days’ wages [ 7 ]. By focusing on the Kenema pharmacies in Lideta Sub-City, this study aimed to fill the existing evidence gap by assessing the availability and affordability of selected essential medicines and examining the socio-demographic factors influencing access. It further evaluated the effectiveness of the KPP in mitigating systemic supply chain failures, a critical consideration for informing future strategies to build resilient, sustainable, and equitable pharmaceutical supply chains. The study also aimed to propose practical solutions to address medicine shortages and improve affordability, with findings that offer valuable policy insights that could be scaled nationally, supporting Ethiopia’s broader goal of achieving universal health coverage. This study provides valuable evidence for multiple stakeholders by examining the operational context of KPP. For policymakers and the Addis Ababa City Administration, it offers critical insights for scaling, resource allocation, and policy adjustments. KPP management and pharmacy staff can use the findings to address inventory and service bottlenecks, while supply chain entities like EPSA gain understanding of upstream disruptions’ downstream effects, emphasizing improved forecasting and logistics. Additionally, the study fills a research gap by providing localized evidence on urban medicine access through a public retail model. Operational Definitions Essential medicines (EMs) are those that address priority health needs as defined by the WHO and the National Essential Medicine List (NEML). A medicine is considered affordable when the total cost of a standard treatment does not exceed one day’s wage of the lowest-paid government worker, which is 36.6 ETB according to WHO guidelines. Availability refers to the presence of unexpired medicines in health facilities as compared with the expected NEML, ensuring that essential treatments are accessible when needed. METHODOLOGY Study Area and Period The study was conducted in the Kenema Pharmacies located in Lideta Sub-City, Addis Ababa. This area was chosen due to its convenience nature, reflecting both urban healthcare dynamics and the operational challenges faced by public pharmacies in Ethiopia. The study population included adult clients of these pharmacies, officials involved in supply chain management, and pharmacy staff who interacted with the supply and distribution process. Data collection took place from December 15 to December 30, 2025. The study area encompassed Lideta Sub-City, which spans approximately 9.62 square kilometers. Within this sub-city, four Kenema Pharmacy branches were identified and included in the study. Kenema Public Pharmacy Lideta Church (No. 08) is situated on Sao Thome & Principe Street, near Lideta Church. Kenema Pharmacy Lideta Condominium Block 41 is located within the Lideta Condominium area at Block 41. Kenema Pharmacy Number 01 Merkato is positioned near the Merkato area, which borders Lideta. Finally, Kenema Pharmacy No. 3 is located around Addis Ababa Stadium. Study Design This research employed a mixed-methods approach, combining both quantitative and qualitative methods to provide a comprehensive understanding of the impact of supply chain disruptions. The quantitative component involved a cross-sectional survey conducted with pharmacy clients to measure the availability and affordability of essential medicines. This study included structured questionnaires administered to a sample of 257 participants, selected through systematic random sampling among adults visiting the four Kenema Pharmacies in Lideta Sub-City. For the qualitative component, the researchers conducted semi-structured interviews with key stakeholders, including EPSA Officials, healthcare providers, and pharmacy staff. These interviews explored the root causes of supply chain disruptions and the strategies employed to mitigate them. The combination of these methods allowed for data triangulation and provided a holistic view of the challenges and potential solutions. Source and Study Population Lideta Sub-City Kenema pharmacy staff and managers, all customers purchasing medicine at the four selected Kenema pharmacies, and available administrative and logistic records. Pharmacy clients (>18 years) and key informants (Kenema Pharmacies staff, managers,). Sample Size Calculation and Technique Since the study was conducted in one sub-city with a known and limited number of pharmacy clients, the finite population correction (FPC) formula was applied. The total number of pharmacy clients in the sub- city during the study period was estimated to be 775 based on pharmacy attendance records. This value represents the finite population size (N). However, due to time and resource constraints, and considering the focused nature of the study within one sub-city, a final sample of 257 pharmacy clients was adopted, with adjustments for feasibility while maintaining statistical relevance. For qualitative insights, 12 key stakeholders were purposively selected, including pharmacy staff, managers, and supply chain officials, to provide in-depth perspectives on supply chain disruptions was used for selecting pharmacy clients to ensure representativeness, while purposive sampling was applied for selecting pharmacy staff and managers to capture expert insights. Systematic random sampling is used for clients and purposive sampling is used for key stakeholders. Purposive sampling was used to select stakeholders with specific expertise relevant to the study objectives. Inclusion and Exclusion Criteria All study variables aged 18 years and above were included. On the other hand, persons with cognitive or communicative impairment and critically ill individuals were excluded. Study Variables The study’s dependent variables are the availability and affordability of essential medicines, while the independent variables include socio-demographic and contextual factors such as sex, age, marital status, family size, residence, occupation, income, and distance from the pharmacy. Data Collection Tools Structured questionnaires were used for the quantitative component, including items on the types of medicines sought, their availability, and out-of-pocket costs incurred by clients, while semi-structured interviews guided the qualitative component to explore supply chain challenges, mitigation strategies, and the impact of recent global events on local medicine supply. Both instruments were developed specifically for this study, informed by relevant literature and tailored to the local context, rather than adopted from previously published tools. The English language versions of the questionnaire and interview guide are provided in the supplementary file. Data Analysis Quantitative data were analyzed using Excel to generate descriptive statistics such as frequencies and proportions, as well as to examine correlations between demographic factors and affordability. Qualitative data were subjected to thematic analysis to identify recurring themes and insights. This dual approach helped in cross-validating findings and provided a robust data presentation. RESULTS Sociodemographic Findings A total of 257 pharmacy clients from Kenema Pharmacies in Lideta Sub-City participated in the study. Most respondents were aged 30–44 years (40.1%), followed by 18–29 years (25.7%), 45–59 years (22.6%), and ≥ 60 years (11.6%). Slightly more than half were male (56.8%), while 43.2% were female. Regarding occupation, 34.6% were self-employed, 22.6% were government employees, 20.2% were private employees, and 22.6% were unemployed, students, or retired. In terms of monthly income, 37.7% earned less than 3,000 ETB, 32.7% earned 3,000–5,000 ETB, 18.3% earned 5,001–8,000 ETB, and 11.3% earned more than 8,000 ETB (Table 1 ). Table 1 Sociodemographic Characteristics of Respondents Variable Category Frequency (n) Percentage (%) Age Group 18–29 66 25.7 30–44 103 40.1 45–59 58 22.6 ≥ 60 30 11.6 Gender Male 146 56.8 Female 111 43.2 Occupation Government employee 58 22.6 Private employee 52 20.2 Self-employed (daily labor, traders) 89 34.6 Unemployed / student / retired 58 22.6 Monthly Income (ETB) 8,000 29 11.3 Quantitative Findings Medicine Availability More than half of the respondents (57.6%) reported difficulty obtaining prescribed medicines within the past three months. Among those who experienced availability issues, 43.6% obtained their medicines on the same day, 33.5% waited 1–3 days, and 22.9% waited more than 3 days to access the required medications (Table 2 ). Table 2 Medicine Availability and Access Among Respondents (N = 257) Variable Category Frequency (n) Percentage (%) Trouble finding medicines in last 3 months Yes 148 57.6 No 109 42.4 Time taken to obtain medicine Same day 112 43.6 1–3 days 86 33.5 > 3 days 59 22.9 The medicines most frequently reported as unavailable included antibiotics such as Amoxicillin, insulin, antihypertensives like Amlodipine, antidiabetics such as Metformin, and inhalers such as Salbutamol. Patients are forced to postpone therapy, miss doses, or look for alternatives from private pharmacies often at much higher costs due to stockouts of these medications (Fig. 1 ). Medicine Affordability Affordability emerged as a significant barrier to medicine access. More than half of respondents (53.3%) rated medicines as either unaffordable (32.3%) or very unaffordable (21.0%), while only 19.8% considered them affordable and 7.8% very affordable. Accordingly, 51.0% reported having failed to purchase prescribed medicines at least once due to high costs. In terms of expenditure per pharmacy visit, 35.4% spent 100–300 ETB, 31.9% spent 301–600 ETB, 18.7% spent more than 600 ETB, and 14.0% spent less than 100 ETB. Health insurance coverage was low, with only 24.5% reporting any coverage; even among the insured, benefits were typically partial (30–50%), and stockouts often forced additional out-of-pocket purchases (Table 3 ). Table 3 Cost, Insurance Coverage, and Affordability of Medicines (N = 257) Variable Category Frequency (n) Percentage (%) Amount paid per visit (ETB) 600 48 18.7 Health insurance coverage Yes 63 24.5 No 194 75.5 Perceived affordability Very unaffordable 54 21.0 Unaffordable 83 32.3 Neutral 49 19.1 Affordable 51 19.8 Very affordable 20 7.8 Failed to buy medicine due to price Yes 131 51.0 No 126 49.0 More than half of the clients perceive medicines as unaffordable (53.3%), while a smaller proportion consider them affordable (28.0%). This indicates that medicine affordability remains a major concern for many clients (Fig. 2 ). Access & Experience Most respondents lived within 3 km of a Kenema Pharmacy, with 36.6% under 1 km and 40.5% between 1–3 km. Convenience ratings were mixed: 32.3% found access convenient and 16.3% very convenient, while 18.3% found it inconvenient and 8.2% very inconvenient. Qualitative feedback highlighted issues such as inconsistent medicine supply, early visits due to limited stock, high prices, and unclear restocking information (Table 4 ). Table 4 Distance to Pharmacy and Convenience Rating (N = 257) Variable Category Frequency (n) Percentage (%) Distance to pharmacy 3 km 59 22.9 Convenience rating Very inconvenient 21 8.2 Inconvenient 47 18.3 Neutral 64 24.9 Convenient 83 32.3 Very convenient 42 16.3 The chart shows that nearly half of respondents (48.2%) found access convenient or very convenient, while a third (33.1%) felt neutral. About 18.7% experienced access as inconvenient or very inconvenient, highlighting some challenges in accessibility (Fig. 3 ). Qualitative Findings Respondents frequently reported inconsistent medicine availability at pharmacies, noting that “medicine is available this week, missing next week.” Such fluctuations disrupted treatment continuity and forced patients to make multiple trips, sometimes without securing the medicines they needed. This irregular supply created uncertainty and frustration among clients relying on essential medications for chronic or acute conditions. Many clients adapted to this challenge by arriving early at the pharmacies, as one respondent noted, “we come early because stock finishes fast.” Limited stock meant that those who arrived later often missed out, highlighting how supply constraints directly affected access. This pattern also reflects the broader issue of unequal medicine distribution and the need for more reliable inventory management in community pharmacies. Cost and communication were additional barriers. Private pharmacies were considered too expensive, limiting affordability for many respondents and forcing some to skip or delay treatment. Furthermore, the lack of clear information on restocking schedules left clients uncertain about when needed medicines would be available. Together, these factors irregular supply, high costs, and poor communication significantly hindered patients’ ability to access essential medications consistently. Impact of Supply Chain Disruption The study demonstrates that supply chain disruptions at Kenema Pharmacies in Lideta Sub-City significantly affect the availability and affordability of essential medicines. Over half of the respondents (57.6%) reported difficulty obtaining prescribed medicines, including antibiotics, insulin, antihypertensives, and antidiabetics, with many experiencing delays of several days. These shortages forced patients to make multiple trips, adapt their schedules, or even forgo treatment. Affordability was also impacted, as 53.3% of participants found medicines unaffordable, and 51% reported failing to purchase prescribed drugs due to high costs. Limited health insurance coverage and inconsistent stock further exacerbated financial and access barriers. Qualitative insights highlighted irregular supply, unclear restocking information, and unequal distribution as key contributors, illustrating how supply chain inefficiencies directly disrupt patient access to essential medications. DISCUSSION The socio-demographic profile of respondents reflects a medically dependent and financially vulnerable urban population. The majority were economically active adults aged 30–44 (40.1%), followed by those 45–59 (22.6%), indicating that most users are responsible not only for their own healthcare needs but also for those of dependents. This age structure increases sensitivity to medicine shortages, particularly for chronic conditions such as hypertension, diabetes, and asthma that require continuous treatment. The presence of elderly respondents (11.6%) further highlights the need for uninterrupted access, as treatment interruptions in this group can quickly lead to health deterioration. The gender distribution (56.8% male, 43.2% female) was relatively balanced, suggesting broad representativeness of findings. Income levels reveal substantial financial vulnerability. Nearly 70% of respondents earned less than 5,000 ETB per month, placing many near or below the urban poverty threshold. Combined with low insurance coverage (24.5%), this creates limited financial resilience against medicine price increases or unexpected health expenditures. These findings align with broader national patterns of low insurance penetration and economic vulnerability documented by Wirtz et al. [ 10 ]. In such a context, even modest increases in medicine prices or the need to purchase from private pharmacies during stockouts can impose significant financial strain, particularly in low- and middle-income countries (LMICs) where out-of-pocket spending dominates [ 6 , 14 ]. Medicine availability at Kenema Pharmacies emerged as inconsistent and unreliable. A majority of respondents (57.6%) experienced difficulty obtaining prescribed medicines within the previous three months, suggesting that stockouts are frequent operational challenges rather than isolated events. Similar medicine availability fluctuations have been documented across LMIC public sectors [ 8 ]. However, 42.4% reported no difficulty, and 43.6% received medicines the same day, indicating that supply disruptions are intermittent rather than absolute. Frequently unavailable medicines included antibiotics, antihypertensives, insulin, antidiabetics, and inhalers critical treatments for both communicable and non-communicable diseases. The recurrent absence of chronic disease medicines has been reported in other Ethiopian studies [ 2 , 4 ]. Delays of at least one day were reported by 56.4% of respondents, increasing the risk of treatment interruption and poor disease control. Compared to earlier Ethiopian studies such as the 34.52% availability of lowest-priced cardiovascular generics reported by Masresha et al. [ 2 ] the findings suggest persistent and possibly worsening public-sector retail supply challenges. Prior research has linked these disruptions to procurement delays, foreign currency shortages, and forecasting weaknesses within the Ethiopian pharmaceutical supply system [ 3 ], indicating that upstream system inefficiencies directly affect patients at the point of care. This systems-level constraint is consistent with broader analyses of medicine access barriers in LMICs [ 15 ]. Affordability was identified as the most severe and enduring barrier. More than half of respondents (53.3%) rated medicines as unaffordable or extremely unaffordable, and 51% reported forgoing purchases due to cost. These findings are comparable to, and in some cases exceed, the 47–63.9% unaffordability range reported by Abdu et al. [ 4 ] and are consistent with national evidence showing high out-of-pocket expenditure burdens [ 1 ]. Evidence from Addis Ababa’s private sector has shown that certain medicines may cost multiple days’ wages, especially when public supply fails [ 5 ], further compounding financial hardship. Expenditure patterns further illustrate the burden: over half of respondents spent more than 300 ETB per pharmacy visit, a considerable expense for low-income households, particularly those managing chronic illnesses requiring monthly refills. Insurance coverage, where available, was often incomplete especially during stockouts when patients were forced to seek medicines from private pharmacies at higher prices. This interaction between availability and affordability demonstrates how supply instability can directly exacerbate financial barriers [ 16 ]. Although geographic access appeared relatively adequate 77% of respondents lived within three kilometers of a Kenema Pharmacy physical proximity did not guarantee effective access. Many reported multiple visits, incomplete prescriptions, or uncertainty about availability and pricing. This supports the multidimensional healthcare access framework proposed by Levesque et al. [ 7 ], which emphasizes that availability, affordability, and acceptability are as important as geographic accessibility. Similar conclusions regarding multidimensional access constraints have been drawn in cross-country LMIC analyses [ 8 ]. Overall, the study demonstrates a cascading effect of supply chain disruptions. National-level procurement and distribution inefficiencies lead to stockouts at Kenema Pharmacies, which in turn cause treatment delays, increased out-of-pocket spending, and reliance on more expensive private alternatives. This downstream manifestation of upstream system weaknesses aligns with health systems perspectives on pharmaceutical sector reform [ 6 ]. While Kenema Pharmacies provide a partial buffer through lower prices and urban coverage, their effectiveness is constrained by systemic supply chain weaknesses. Addressing medicine access challenges therefore requires comprehensive upstream reforms alongside strengthened financial protection mechanisms to ensure equitable and sustainable access [ 1 , 16 ]. CONCLUSION The study shows that supply chain disruptions significantly limit the capacity of Kenema Pharmacies to ensure consistent availability and affordability of essential medicines in Lideta Sub-City. While these public pharmacies offer lower prices and better geographic access than private providers, medicine supply remains inconsistent due to systemic inefficiencies in national forecasting, procurement, and distribution. Frequent stockouts of high-demand essential medicines result in treatment delays, incomplete prescriptions, and increased reliance on more expensive private pharmacies. Affordability is a persistent challenge, particularly for low-income and uninsured households. Even when medicines are available, costs often exceed household budgets. Supply interruptions further worsen this burden by forcing patients into private markets with higher prices, increasing out-of-pocket spending and reducing treatment adherence. Although geographic access to Kenema Pharmacies is relatively good, physical proximity alone does not guarantee effective access when availability and financial barriers persist. To improve medicine access in Lideta Sub-City, supply chain management should be strengthened through better forecasting, timely procurement, and efficient distribution to reduce stockouts at Kenema Pharmacies. Expanding health insurance coverage, ensuring benefits apply during stockouts, and targeted subsidies for essential medicines would improve affordability for low-income households. Real-time inventory monitoring, transparent procurement, and oversight of private-sector pricing can further stabilize availability and reduce out-of-pocket costs, ensuring more equitable and reliable access to essential medicines. Some limitations should be acknowledged. The cross-sectional design captures only a single point in time and cannot establish causality or trends. The study was limited to one sub-city, which may restrict generalizability to other areas. Affordability assessment relied mainly on self-reported perceptions and expenditures rather than standardized wage-based measures, and recall bias may have affected responses. Additionally, limited input from higher-level supply chain policymakers may have constrained the depth of analysis regarding upstream system challenges. Declarations Ethical approval and consent to participate Ethical approval was obtained from the Africa Medical College Research and Community Service Office. All study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki. Informed consent was obtained from all participants, and confidentiality and anonymity were strictly maintained. Participation was voluntary, and participants had the right to decline any question or withdraw from the study at any time without pressure. Clinical trial number ‘Not applicable’ Consent for publication ‘Not applicable’ Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to privacy and ethical concerns but are available from the corresponding author upon reasonable request. Co mpeting interest s The authors declare that they have no competing interests. Funding ‘Not applicable’ Authors' contributions N.S., H.Z., F.A., and F.A. drafted the proposal work, synthesized the appropriate methodology, conducted the data analysis, generated the results, and forwarded the relevant conclusions. H.S. provided the analysis, limitation, discussion section and write up of the study. A.A. contributed relevant discussion and recommendations for the study. M.T. contributed to limitation and write up of the study. All authors read and approved the final manuscript. Acknowledgments We would like to thank the Africa Medical College Research & Community Service Office for providing the opportunity to conduct this research. We also appreciate the management of Kenema pharmacies in Lideta sub-city for their cooperation, and we are grateful to all pharmacy clients who generously gave their time to participate in the study. References World Health Organization. The selection of essential medicines. Geneva: World Health Organization; 2017. World Health Organization. Essential medicines list: 22nd list. Geneva: World Health Organization; 2023. Berhane G, Beshir H. Supply chain challenges in Ethiopia’s pharmaceutical sector. J Pharm Policy Pract. 2021;14(2):34–48. United Nations. Sustainable development goals: Goal 3. New York: United Nations; 2015. Gebrehiwot T. Case study on Kenema Pharmacies Enterprise (KPP). Addis Ababa; 2023. Masresha R, et al. 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Baseline assessment of WHO’s target for both availability and affordability of essential medicines in the WHO Eastern Mediterranean Region. BMC Health Serv Res. 2019;19(1):54. Yadav P. Ensuring medicines supply during the COVID-19 pandemic: Navigating the challenges of a global health crisis. J Pharm Policy Pract. 2020;13:12–21. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):18. Ministry of Health. Ethiopia’s national essential medicine list. Addis Ababa: Ministry of Health; 2021. Yimer G, Tilahun M, Makonnen E. Availability and affordability of essential medicines in Ethiopia: A national survey. Ethiop J Health Sci. 2016;26(4):387–396. Additional Declarations No competing interests reported. Supplementary Files QuestionerandInterviewGuidesEnglish.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 01 May, 2026 Reviewers invited by journal 29 Apr, 2026 Editor invited by journal 07 Apr, 2026 Editor assigned by journal 06 Apr, 2026 Submission checks completed at journal 06 Apr, 2026 First submitted to journal 05 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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College","correspondingAuthor":false,"prefix":"","firstName":"Hadas","middleName":"","lastName":"Zeru","suffix":""},{"id":635774010,"identity":"c0d91ded-03e7-45e3-bac6-8aa89ae03843","order_by":2,"name":"Fenan Aklilu","email":"","orcid":"","institution":"Africa Medical College","correspondingAuthor":false,"prefix":"","firstName":"Fenan","middleName":"","lastName":"Aklilu","suffix":""},{"id":635774012,"identity":"8ac42413-cc57-49ac-95fe-72147fd59347","order_by":3,"name":"Fakiha Ali","email":"","orcid":"","institution":"Africa Medical College","correspondingAuthor":false,"prefix":"","firstName":"Fakiha","middleName":"","lastName":"Ali","suffix":""},{"id":635774014,"identity":"4044fd40-1527-48ec-b2dc-0bfdfcbef0c2","order_by":4,"name":"Habtamu Solomon 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University","correspondingAuthor":false,"prefix":"","firstName":"Abinet","middleName":"","lastName":"Abebe","suffix":""},{"id":635774016,"identity":"989ce224-9c72-4437-8089-ed04cd66d527","order_by":6,"name":"Manaye Tamrie Derseh","email":"","orcid":"","institution":"Debre Markos University","correspondingAuthor":false,"prefix":"","firstName":"Manaye","middleName":"Tamrie","lastName":"Derseh","suffix":""}],"badges":[],"createdAt":"2026-04-05 20:54:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9328438/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9328438/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108806097,"identity":"9b42b320-d990-451a-9def-2dad54e8e785","added_by":"auto","created_at":"2026-05-08 15:27:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45553,"visible":true,"origin":"","legend":"\u003cp\u003eCommon therapeutic categories requiring counseling\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9328438/v1/4dea2a1c48fc50c45c1fe775.png"},{"id":108680696,"identity":"a37e5720-4175-40eb-a906-e2a5ea749a1e","added_by":"auto","created_at":"2026-05-07 09:16:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47807,"visible":true,"origin":"","legend":"\u003cp\u003eClient perception of medicine affordability\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9328438/v1/e922ad7f12cb0465341f0ed7.png"},{"id":108806079,"identity":"5d185824-72ec-4b4f-b6c8-730e82a3a0ad","added_by":"auto","created_at":"2026-05-08 15:27:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":46982,"visible":true,"origin":"","legend":"\u003cp\u003eRespondents’ perception of medicine access\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9328438/v1/772a2ce079112e6a9663ac9d.png"},{"id":108814601,"identity":"5ff34380-559b-4124-b9e7-06dae0744a01","added_by":"auto","created_at":"2026-05-08 16:18:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":442324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9328438/v1/40879485-ddf3-46a5-9594-5ed648ca9aab.pdf"},{"id":108680694,"identity":"648192f8-a0ec-43c2-a51b-898ebd0e035b","added_by":"auto","created_at":"2026-05-07 09:16:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27162,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionerandInterviewGuidesEnglish.docx","url":"https://assets-eu.researchsquare.com/files/rs-9328438/v1/e6b289a7723a54d91d6173ca.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Supply Chain Disruptions on the Availability and Affordability of Essential Medicines at Kenema Pharmacies in Addis Ababa, Ethiopia","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHealth was widely recognized as a fundamental human right, and ensuring equitable access to essential medicines (EMs) was a cornerstone of that principle [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Essential medicines are those that address the priority healthcare needs of a population, selected with regard to disease prevalence, evidence on efficacy, and comparative cost-effectiveness [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Ethiopia, the Ethiopian Pharmaceutical Supply Agency (EPSA) played a central role in the procurement, storage, and distribution of these medicines. However, EPSA struggled with persistent challenges like inaccurate forecasting, long procurement cycles, and data coordination issues [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese supply chain disruptions often resulted in stock-outs, medicine wastage, and treatment delays, which exacerbated health inequities and hindered progress toward Sustainable Development Goal three [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Global crises like the COVID-19 pandemic further worsened these disruptions, especially in rural and underserved areas.\u003c/p\u003e \u003cp\u003eAs part of the government\u0026rsquo;s effort to ensure access to medication, Kenema Pharmacies Partnership (KPP) operated as a government-owned public retail pharmacy chain established under the Addis Ababa City Administration. The enterprise was founded to improve equitable access to essential medicines and to offer more affordable pharmaceutical services for residents of Addis Ababa and surrounding areas. According to a case study of KPP, the mission statement explicitly included providing \u0026ldquo;life-saving medicines at an affordable price\u0026rdquo; and supplying required drugs in type and quantity for the wellbeing of the community [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs such, KPP represented the government\u0026rsquo;s strategic intervention to counteract common market failures in medicine accessibility, especially in urban low-income settings where private retail pharmacies often operated at higher price points or faced supply constraints.\u003c/p\u003e \u003cp\u003eThis study focused on evaluating the Kenema Pharmacies chains in the Lideta Sub-City of Addis Ababa as a representative case to highlight the broader national impacts of challenges to affordable access to medication. By providing evidence-based insights, it aimed to inform policy reforms that could strengthen the resilience of Ethiopia\u0026rsquo;s medicine supply chain.\u003c/p\u003e \u003cp\u003eKenema Pharmacies operated a network of retail pharmacies throughout Addis Ababa, focusing on affordability and equitable access, particularly for low-income populations that were typically underserved by private pharmacies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Through this model, the government sought to bridge the gap left by inefficiencies in the private sector and EPSA\u0026rsquo;s centralized supply chain, which was often strained due to funding shortages, logistical delays, and procurement bottlenecks.\u003c/p\u003e \u003cp\u003eAlthough disaggregated performance data specifically for individual Kenema Pharmacies branches was not available, the general picture of essential medicine availability and affordability in Addis Ababa remained concerning. A recent study on generic cardiovascular medicines found that the availability of lowest-priced generics (LPGs) was only 34.52%, with public sector availability at 33.73% and private pharmacies at 29.8% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Similarly, a cross-sectional study on psychotropic medicines revealed that the mean availability of LPGs in Addis Ababa was 24.33%, with standard treatment costs ranging from 0.1 to 7.8 days\u0026rsquo; wages in the public sector and 0.8 to 25 days\u0026rsquo; wages in the private sector [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These findings pointed to serious challenges not only in stock availability but also in affordability, with high prices making treatments inaccessible for most wage-earning patients.\u003c/p\u003e \u003cp\u003eThese issues disproportionately affected vulnerable populations, especially those living in urban low-income settings such as Lideta Sub city. Without access to essential medications, these populations faced an increased risk of disease progression, preventable complications, and high health expenditures. Additionally, the lack of reliable access to affordable medication could lead to reduced trust in the public health system and increased reliance on informal or unregulated medicine sources. Despite these challenges, there was limited empirical research assessing the effectiveness of public pharmacies like KPP in mitigating the effects of supply chain disruptions and providing affordable, quality-assured medicines [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccess to essential medicines is a critical determinant of health outcomes globally. Numerous studies have established that when populations have reliable access to affordable medicines, there are significant improvements in overall public health indicators, including reduced morbidity and mortality rates [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA meta-analysis by Cameron found that the availability of medicines in low- and middle-income countries ranges from as low as 24% to as high as 80%, with public sector availability typically on the lower end of that spectrum [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Ethiopia, the challenge of medicine availability and affordability is compounded by economic constraints, logistical issues, and infrastructural limitations [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A study by Abdu highlighted that about 47-63.9% of essential medicines are unaffordable for the average Ethiopian household, particularly impacting rural communities and those working in informal sectors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature also points to several deeper factors influencing medicine access. These include policy and regulatory environments, the efficiency of national procurement and distribution systems, and the role of international donor support [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For instance, Wirtz note that countries with strong regulatory frameworks and robust supply chain governance tend to perform better in ensuring continuous availability of essential medicines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the Ethiopian context, the role of the Ethiopian Pharmaceutical Supply Agency (EPSA) is pivotal. While EPSA has made strides in improving the supply chain, challenges remain in terms of forecasting accuracy, timely procurement, and distribution logistics [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These systemic issues are further influenced by global supply chain disruptions, such as those seen during the COVID-19 pandemic, which have underscored the need for more resilient and adaptive supply chain mechanisms [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRobust policy and regulatory environments are critical for ensuring sustainable access to medicines. Countries with strong governance structures and transparent regulatory systems tend to perform better in maintaining consistent medicine availability [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Ethiopia, ongoing health system reforms, including the expansion of health insurance and public pharmacy networks, represent key policy initiatives aimed at improving access.\u003c/p\u003e \u003cp\u003eThe establishment of KPP signifies a strategic public‑sector intervention by the Addis Ababa City Administration to enhance access to essential medicines by expanding government‑owned retail pharmacy services in urban Ethiopia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to a case study, KPP currently operates 43 branches within Addis Ababa and serves a wide customer base, yet the research indicates that this branch network remains insufficient to meet city‑wide demand.\u003c/p\u003e \u003cp\u003eThe study revealed that weekly average customer numbers for KPP branches ranged from 587 to 1,848 depending on pharmacy class, and that the average dispensing time was only 1.6 minutes suggesting high workload and potential constraints on service quality. Given the broader national evidence of medicine availability and affordability challenges, the role of KPP deserves close evaluation. For example, studies in Addis Ababa demonstrate that availability of lowest priced generics (LPGs) for cardiovascular disease medicines was only 34.52% overall, with public sector availability at 33.73% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and that psychotropic LPGs had a mean availability of 24.33%, with private‑sector access costs reaching 25 days\u0026rsquo; wages [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy focusing on the Kenema pharmacies in Lideta Sub-City, this study aimed to fill the existing evidence gap by assessing the availability and affordability of selected essential medicines and examining the socio-demographic factors influencing access. It further evaluated the effectiveness of the KPP in mitigating systemic supply chain failures, a critical consideration for informing future strategies to build resilient, sustainable, and equitable pharmaceutical supply chains. The study also aimed to propose practical solutions to address medicine shortages and improve affordability, with findings that offer valuable policy insights that could be scaled nationally, supporting Ethiopia\u0026rsquo;s broader goal of achieving universal health coverage.\u003c/p\u003e \u003cp\u003eThis study provides valuable evidence for multiple stakeholders by examining the operational context of KPP. For policymakers and the Addis Ababa City Administration, it offers critical insights for scaling, resource allocation, and policy adjustments. KPP management and pharmacy staff can use the findings to address inventory and service bottlenecks, while supply chain entities like EPSA gain understanding of upstream disruptions\u0026rsquo; downstream effects, emphasizing improved forecasting and logistics. Additionally, the study fills a research gap by providing localized evidence on urban medicine access through a public retail model.\u003c/p\u003e \u003cp\u003eOperational Definitions\u003c/p\u003e \u003cp\u003eEssential medicines (EMs) are those that address priority health needs as defined by the WHO and the National Essential Medicine List (NEML). A medicine is considered affordable when the total cost of a standard treatment does not exceed one day\u0026rsquo;s wage of the lowest-paid government worker, which is 36.6 ETB according to WHO guidelines. Availability refers to the presence of unexpired medicines in health facilities as compared with the expected NEML, ensuring that essential treatments are accessible when needed.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eStudy Area and Period\u003c/p\u003e\n\u003cp\u003eThe study was conducted in the Kenema Pharmacies located in Lideta Sub-City, Addis Ababa. This area was chosen due to its convenience nature, reflecting both urban healthcare dynamics and the operational challenges faced by public pharmacies in Ethiopia. The study population included adult clients of these pharmacies, officials involved in supply chain management, and pharmacy staff who interacted with the supply and distribution process. Data collection took place from December 15 to December 30, 2025. The study area encompassed Lideta Sub-City, which spans approximately 9.62 square kilometers.\u003c/p\u003e\n\u003cp\u003eWithin this sub-city, four Kenema Pharmacy branches were identified and included in the study. Kenema Public Pharmacy Lideta Church (No. 08) is situated on Sao Thome \u0026amp; Principe Street, near Lideta Church. Kenema Pharmacy Lideta Condominium Block 41 is located within the Lideta Condominium area at Block 41. Kenema Pharmacy Number 01 Merkato is positioned near the Merkato area, which borders Lideta. Finally, Kenema Pharmacy No. 3 is located around Addis Ababa Stadium.\u003c/p\u003e\n\u003cp\u003eStudy Design\u003c/p\u003e\n\u003cp\u003eThis research employed a mixed-methods approach, combining both quantitative and qualitative methods to provide a comprehensive understanding of the impact of supply chain disruptions. The quantitative component involved a cross-sectional survey conducted with pharmacy clients to measure the availability and affordability of essential medicines. This study included structured questionnaires administered to a sample of 257 participants, selected through systematic random sampling among adults visiting the four Kenema Pharmacies in Lideta Sub-City.\u003c/p\u003e\n\u003cp\u003eFor the qualitative component, the researchers conducted semi-structured interviews with key stakeholders, including EPSA Officials, healthcare providers, and pharmacy staff. These interviews explored the root causes of supply chain disruptions and the strategies employed to mitigate them. The combination of these methods allowed for data triangulation and provided a holistic view of the challenges and potential solutions.\u003c/p\u003e\n\u003cp\u003eSource and Study Population\u003c/p\u003e\n\u003cp\u003eLideta Sub-City Kenema pharmacy staff and managers, all customers purchasing medicine at the four selected Kenema pharmacies, and available administrative and logistic records. Pharmacy clients (\u0026gt;18 years) and key informants (Kenema Pharmacies staff, managers,).\u003c/p\u003e\n\u003cp\u003eSample Size Calculation and Technique\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince the study was conducted in one sub-city with a known and limited number of pharmacy clients, the finite population correction (FPC) formula was applied. The total number of pharmacy clients in the sub- city during the study period was estimated to be 775 based on pharmacy attendance records. This value represents the finite population size (N).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg 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\" style=\"width: 572px; height: 302.261px;\" width=\"572\" height=\"302.261\"\u003e\u003c/p\u003e\n\u003cp\u003eHowever, due to time and resource constraints, and considering the focused nature of the study within one sub-city, a final sample of 257 pharmacy clients was adopted, with adjustments for feasibility while maintaining statistical relevance.\u003c/p\u003e\n\u003cp\u003eFor qualitative insights, 12 key stakeholders were purposively selected, including pharmacy staff, managers, and supply chain officials, to provide in-depth perspectives on supply chain disruptions was used for selecting pharmacy clients to ensure representativeness, while purposive sampling was applied for selecting pharmacy staff and managers to capture expert insights.\u003c/p\u003e\n\u003cp\u003eSystematic random sampling is used for clients and purposive sampling is used for key stakeholders. Purposive sampling was used to select stakeholders with specific expertise relevant to the study objectives.\u003c/p\u003e\n\u003cp\u003eInclusion and Exclusion Criteria\u003c/p\u003e\n\u003cp\u003eAll study variables aged 18 years and above were included. On the other hand, persons with cognitive or communicative impairment and critically ill individuals were excluded.\u003c/p\u003e\n\u003cp\u003eStudy Variables\u003c/p\u003e\n\u003cp\u003eThe study\u0026rsquo;s dependent variables are the availability and affordability of essential medicines, while the independent variables include socio-demographic and contextual factors such as sex, age, marital status, family size, residence, occupation, income, and distance from the pharmacy.\u003c/p\u003e\n\u003cp\u003eData Collection Tools\u003c/p\u003e\n\u003cp\u003eStructured questionnaires were used for the quantitative component, including items on the types of medicines sought, their availability, and out-of-pocket costs incurred by clients, while semi-structured interviews guided the qualitative component to explore supply chain challenges, mitigation strategies, and the impact of recent global events on local medicine supply. Both instruments were developed specifically for this study, informed by relevant literature and tailored to the local context, rather than adopted from previously published tools. The English language versions of the questionnaire and interview guide are provided in the supplementary file.\u003c/p\u003e\n\u003cp\u003eData Analysis\u003c/p\u003e\n\u003cp\u003eQuantitative data were analyzed using Excel to generate descriptive statistics such as frequencies and proportions, as well as to examine correlations between demographic factors and affordability. Qualitative data were subjected to thematic analysis to identify recurring themes and insights. This dual approach helped in cross-validating findings and provided a robust data presentation.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic Findings\u003c/h2\u003e \u003cp\u003eA total of 257 pharmacy clients from Kenema Pharmacies in Lideta Sub-City participated in the study. Most respondents were aged 30\u0026ndash;44 years (40.1%), followed by 18\u0026ndash;29 years (25.7%), 45\u0026ndash;59 years (22.6%), and \u0026ge;\u0026thinsp;60 years (11.6%). Slightly more than half were male (56.8%), while 43.2% were female. Regarding occupation, 34.6% were self-employed, 22.6% were government employees, 20.2% were private employees, and 22.6% were unemployed, students, or retired. In terms of monthly income, 37.7% earned less than 3,000 ETB, 32.7% earned 3,000\u0026ndash;5,000 ETB, 18.3% earned 5,001\u0026ndash;8,000 ETB, and 11.3% earned more than 8,000 ETB (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic Characteristics of Respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed (daily labor, traders)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed / student / retired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Income (ETB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,000\u0026ndash;5,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,001\u0026ndash;8,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cp\u003eMedicine Availability\u003c/p\u003e \u003cp\u003eMore than half of the respondents (57.6%) reported difficulty obtaining prescribed medicines within the past three months. Among those who experienced availability issues, 43.6% obtained their medicines on the same day, 33.5% waited 1\u0026ndash;3 days, and 22.9% waited more than 3 days to access the required medications (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedicine Availability and Access Among Respondents (N\u0026thinsp;=\u0026thinsp;257)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrouble finding medicines in last 3 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime taken to obtain medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSame day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe medicines most frequently reported as unavailable included antibiotics such as Amoxicillin, insulin, antihypertensives like Amlodipine, antidiabetics such as Metformin, and inhalers such as Salbutamol. Patients are forced to postpone therapy, miss doses, or look for alternatives from private pharmacies often at much higher costs due to stockouts of these medications (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMedicine Affordability\u003c/p\u003e \u003cp\u003eAffordability emerged as a significant barrier to medicine access. More than half of respondents (53.3%) rated medicines as either unaffordable (32.3%) or very unaffordable (21.0%), while only 19.8% considered them affordable and 7.8% very affordable. Accordingly, 51.0% reported having failed to purchase prescribed medicines at least once due to high costs. In terms of expenditure per pharmacy visit, 35.4% spent 100\u0026ndash;300 ETB, 31.9% spent 301\u0026ndash;600 ETB, 18.7% spent more than 600 ETB, and 14.0% spent less than 100 ETB. Health insurance coverage was low, with only 24.5% reporting any coverage; even among the insured, benefits were typically partial (30\u0026ndash;50%), and stockouts often forced additional out-of-pocket purchases (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCost, Insurance Coverage, and Affordability of Medicines (N\u0026thinsp;=\u0026thinsp;257)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmount paid per visit (ETB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u0026ndash;300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e301\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth insurance coverage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived affordability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery unaffordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnaffordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAffordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery affordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFailed to buy medicine due to price\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMore than half of the clients perceive medicines as unaffordable (53.3%), while a smaller proportion consider them affordable (28.0%). This indicates that medicine affordability remains a major concern for many clients (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAccess \u0026amp; Experience\u003c/p\u003e \u003cp\u003eMost respondents lived within 3 km of a Kenema Pharmacy, with 36.6% under 1 km and 40.5% between 1\u0026ndash;3 km. Convenience ratings were mixed: 32.3% found access convenient and 16.3% very convenient, while 18.3% found it inconvenient and 8.2% very inconvenient. Qualitative feedback highlighted issues such as inconsistent medicine supply, early visits due to limited stock, high prices, and unclear restocking information (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistance to Pharmacy and Convenience Rating (N\u0026thinsp;=\u0026thinsp;257)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistance to pharmacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 km\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3 km\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 km\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConvenience rating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery inconvenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInconvenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConvenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery convenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe chart shows that nearly half of respondents (48.2%) found access convenient or very convenient, while a third (33.1%) felt neutral. About 18.7% experienced access as inconvenient or very inconvenient, highlighting some challenges in accessibility (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Findings\u003c/h3\u003e\n\u003cp\u003eRespondents frequently reported inconsistent medicine availability at pharmacies, noting that \u0026ldquo;medicine is available this week, missing next week.\u0026rdquo; Such fluctuations disrupted treatment continuity and forced patients to make multiple trips, sometimes without securing the medicines they needed. This irregular supply created uncertainty and frustration among clients relying on essential medications for chronic or acute conditions.\u003c/p\u003e \u003cp\u003eMany clients adapted to this challenge by arriving early at the pharmacies, as one respondent noted, \u0026ldquo;we come early because stock finishes fast.\u0026rdquo; Limited stock meant that those who arrived later often missed out, highlighting how supply constraints directly affected access. This pattern also reflects the broader issue of unequal medicine distribution and the need for more reliable inventory management in community pharmacies.\u003c/p\u003e \u003cp\u003eCost and communication were additional barriers. Private pharmacies were considered too expensive, limiting affordability for many respondents and forcing some to skip or delay treatment. Furthermore, the lack of clear information on restocking schedules left clients uncertain about when needed medicines would be available. Together, these factors irregular supply, high costs, and poor communication significantly hindered patients\u0026rsquo; ability to access essential medications consistently.\u003c/p\u003e\n\u003ch3\u003eImpact of Supply Chain Disruption\u003c/h3\u003e\n\u003cp\u003eThe study demonstrates that supply chain disruptions at Kenema Pharmacies in Lideta Sub-City significantly affect the availability and affordability of essential medicines. Over half of the respondents (57.6%) reported difficulty obtaining prescribed medicines, including antibiotics, insulin, antihypertensives, and antidiabetics, with many experiencing delays of several days. These shortages forced patients to make multiple trips, adapt their schedules, or even forgo treatment. Affordability was also impacted, as 53.3% of participants found medicines unaffordable, and 51% reported failing to purchase prescribed drugs due to high costs. Limited health insurance coverage and inconsistent stock further exacerbated financial and access barriers. Qualitative insights highlighted irregular supply, unclear restocking information, and unequal distribution as key contributors, illustrating how supply chain inefficiencies directly disrupt patient access to essential medications.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe socio-demographic profile of respondents reflects a medically dependent and financially vulnerable urban population. The majority were economically active adults aged 30\u0026ndash;44 (40.1%), followed by those 45\u0026ndash;59 (22.6%), indicating that most users are responsible not only for their own healthcare needs but also for those of dependents. This age structure increases sensitivity to medicine shortages, particularly for chronic conditions such as hypertension, diabetes, and asthma that require continuous treatment. The presence of elderly respondents (11.6%) further highlights the need for uninterrupted access, as treatment interruptions in this group can quickly lead to health deterioration. The gender distribution (56.8% male, 43.2% female) was relatively balanced, suggesting broad representativeness of findings.\u003c/p\u003e \u003cp\u003eIncome levels reveal substantial financial vulnerability. Nearly 70% of respondents earned less than 5,000 ETB per month, placing many near or below the urban poverty threshold. Combined with low insurance coverage (24.5%), this creates limited financial resilience against medicine price increases or unexpected health expenditures. These findings align with broader national patterns of low insurance penetration and economic vulnerability documented by Wirtz et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In such a context, even modest increases in medicine prices or the need to purchase from private pharmacies during stockouts can impose significant financial strain, particularly in low- and middle-income countries (LMICs) where out-of-pocket spending dominates [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMedicine availability at Kenema Pharmacies emerged as inconsistent and unreliable. A majority of respondents (57.6%) experienced difficulty obtaining prescribed medicines within the previous three months, suggesting that stockouts are frequent operational challenges rather than isolated events. Similar medicine availability fluctuations have been documented across LMIC public sectors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, 42.4% reported no difficulty, and 43.6% received medicines the same day, indicating that supply disruptions are intermittent rather than absolute. Frequently unavailable medicines included antibiotics, antihypertensives, insulin, antidiabetics, and inhalers critical treatments for both communicable and non-communicable diseases. The recurrent absence of chronic disease medicines has been reported in other Ethiopian studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Delays of at least one day were reported by 56.4% of respondents, increasing the risk of treatment interruption and poor disease control.\u003c/p\u003e \u003cp\u003eCompared to earlier Ethiopian studies such as the 34.52% availability of lowest-priced cardiovascular generics reported by Masresha et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] the findings suggest persistent and possibly worsening public-sector retail supply challenges. Prior research has linked these disruptions to procurement delays, foreign currency shortages, and forecasting weaknesses within the Ethiopian pharmaceutical supply system [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], indicating that upstream system inefficiencies directly affect patients at the point of care. This systems-level constraint is consistent with broader analyses of medicine access barriers in LMICs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAffordability was identified as the most severe and enduring barrier. More than half of respondents (53.3%) rated medicines as unaffordable or extremely unaffordable, and 51% reported forgoing purchases due to cost. These findings are comparable to, and in some cases exceed, the 47\u0026ndash;63.9% unaffordability range reported by Abdu et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and are consistent with national evidence showing high out-of-pocket expenditure burdens [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Evidence from Addis Ababa\u0026rsquo;s private sector has shown that certain medicines may cost multiple days\u0026rsquo; wages, especially when public supply fails [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], further compounding financial hardship.\u003c/p\u003e \u003cp\u003eExpenditure patterns further illustrate the burden: over half of respondents spent more than 300 ETB per pharmacy visit, a considerable expense for low-income households, particularly those managing chronic illnesses requiring monthly refills. Insurance coverage, where available, was often incomplete especially during stockouts when patients were forced to seek medicines from private pharmacies at higher prices. This interaction between availability and affordability demonstrates how supply instability can directly exacerbate financial barriers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough geographic access appeared relatively adequate 77% of respondents lived within three kilometers of a Kenema Pharmacy physical proximity did not guarantee effective access. Many reported multiple visits, incomplete prescriptions, or uncertainty about availability and pricing. This supports the multidimensional healthcare access framework proposed by Levesque et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which emphasizes that availability, affordability, and acceptability are as important as geographic accessibility. Similar conclusions regarding multidimensional access constraints have been drawn in cross-country LMIC analyses [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the study demonstrates a cascading effect of supply chain disruptions. National-level procurement and distribution inefficiencies lead to stockouts at Kenema Pharmacies, which in turn cause treatment delays, increased out-of-pocket spending, and reliance on more expensive private alternatives. This downstream manifestation of upstream system weaknesses aligns with health systems perspectives on pharmaceutical sector reform [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While Kenema Pharmacies provide a partial buffer through lower prices and urban coverage, their effectiveness is constrained by systemic supply chain weaknesses. Addressing medicine access challenges therefore requires comprehensive upstream reforms alongside strengthened financial protection mechanisms to ensure equitable and sustainable access [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe study shows that supply chain disruptions significantly limit the capacity of Kenema Pharmacies to ensure consistent availability and affordability of essential medicines in Lideta Sub-City. While these public pharmacies offer lower prices and better geographic access than private providers, medicine supply remains inconsistent due to systemic inefficiencies in national forecasting, procurement, and distribution. Frequent stockouts of high-demand essential medicines result in treatment delays, incomplete prescriptions, and increased reliance on more expensive private pharmacies.\u003c/p\u003e \u003cp\u003eAffordability is a persistent challenge, particularly for low-income and uninsured households. Even when medicines are available, costs often exceed household budgets. Supply interruptions further worsen this burden by forcing patients into private markets with higher prices, increasing out-of-pocket spending and reducing treatment adherence. Although geographic access to Kenema Pharmacies is relatively good, physical proximity alone does not guarantee effective access when availability and financial barriers persist.\u003c/p\u003e \u003cp\u003eTo improve medicine access in Lideta Sub-City, supply chain management should be strengthened through better forecasting, timely procurement, and efficient distribution to reduce stockouts at Kenema Pharmacies. Expanding health insurance coverage, ensuring benefits apply during stockouts, and targeted subsidies for essential medicines would improve affordability for low-income households. Real-time inventory monitoring, transparent procurement, and oversight of private-sector pricing can further stabilize availability and reduce out-of-pocket costs, ensuring more equitable and reliable access to essential medicines.\u003c/p\u003e \u003cp\u003eSome limitations should be acknowledged. The cross-sectional design captures only a single point in time and cannot establish causality or trends. The study was limited to one sub-city, which may restrict generalizability to other areas. Affordability assessment relied mainly on self-reported perceptions and expenditures rather than standardized wage-based measures, and recall bias may have affected responses. Additionally, limited input from higher-level supply chain policymakers may have constrained the depth of analysis regarding upstream system challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Africa Medical College Research and Community Service Office. All study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki. Informed consent was obtained from all participants, and confidentiality and anonymity were strictly maintained. Participation was voluntary, and participants had the right to decline any question or withdraw from the study at any time without pressure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Not applicable\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Not applicable\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to privacy and ethical concerns but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCo\u003c/strong\u003e\u003cstrong\u003empeting\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;interest\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Not applicable\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.S., H.Z., F.A., and F.A. drafted the proposal work, synthesized the appropriate methodology, conducted the data analysis, generated the results, and forwarded the relevant conclusions. H.S. provided the analysis, limitation, discussion section and write up of the study. A.A. contributed relevant discussion and recommendations for the study. M.T. contributed to limitation and write up of the study. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the Africa Medical College Research \u0026amp; Community Service Office for providing the opportunity to conduct this research. We also appreciate the management of Kenema pharmacies in Lideta sub-city for their cooperation, and we are grateful to all pharmacy clients who generously gave their time to participate in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. The selection of essential medicines. Geneva: World Health Organization; 2017.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Essential medicines list: 22nd list. Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eBerhane G, Beshir H. Supply chain challenges in Ethiopia\u0026rsquo;s pharmaceutical sector. J Pharm Policy Pract. 2021;14(2):34\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eUnited Nations. Sustainable development goals: Goal 3. New York: United Nations; 2015.\u003c/li\u003e\n\u003cli\u003eGebrehiwot T. Case study on Kenema Pharmacies Enterprise (KPP). Addis Ababa; 2023.\u003c/li\u003e\n\u003cli\u003eMasresha R, et al. Availability, price, and affordability of LPG essential medicines for cardiovascular disease in Addis Ababa, Ethiopia. Sci Rep. 2024; 14:82919.\u003c/li\u003e\n\u003cli\u003eTeshager M, Araya M, Fenta TG. Access to essential psychotropic medicines in Addis Ababa: A cross-sectional study. PLoS One. 2023;18(7):e0283348.\u003c/li\u003e\n\u003cli\u003eBigdeli M, Jacobs B, Tomson G, Laing R. Access to medicines from a health systems perspective. Health Policy Plan. 2013;28(7):692\u0026ndash;704.\u003c/li\u003e\n\u003cli\u003eCameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. Medicine prices, availability, and affordability in 36 developing and middle-income countries: A secondary analysis. Lancet. 2009;373(9659):240\u0026ndash;249.\u003c/li\u003e\n\u003cli\u003eWirtz VJ, Hogerzeil HV, Gray AL, Bigdeli M, de Joncheere CP, Ewen MA, et al. Essential medicines for universal health coverage. Lancet. 2017;389(10067):403\u0026ndash;476.\u003c/li\u003e\n\u003cli\u003eAbdu Y, Gebreyesus T, Tadesse M. Affordability of essential medicines in Ethiopia: An assessment of public sector pharmacies. J Pharm Policy Pract. 2020;13(1):15\u0026ndash;28.\u003c/li\u003e\n\u003cli\u003eEwen M, Zweekhorst M, Regeer B, Laing R. Baseline assessment of WHO\u0026rsquo;s target for both availability and affordability of essential medicines in the WHO Eastern Mediterranean Region. BMC Health Serv Res. 2019;19(1):54.\u003c/li\u003e\n\u003cli\u003eYadav P. Ensuring medicines supply during the COVID-19 pandemic: Navigating the challenges of a global health crisis. J Pharm Policy Pract. 2020;13:12\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eLevesque JF, Harris MF, Russell G. Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):18.\u003c/li\u003e\n\u003cli\u003eMinistry of Health. Ethiopia\u0026rsquo;s national essential medicine list. Addis Ababa: Ministry of Health; 2021.\u003c/li\u003e\n\u003cli\u003eYimer G, Tilahun M, Makonnen E. Availability and affordability of essential medicines in Ethiopia: A national survey. Ethiop J Health Sci. 2016;26(4):387\u0026ndash;396.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"availability, affordability, supply chain disruption, inventory management","lastPublishedDoi":"10.21203/rs.3.rs-9328438/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9328438/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Supply chain disruptions critically threaten essential medicine access in low- and middle-income countries like Ethiopia. Kenema Pharmacies, a public-sector initiative in Addis Ababa, was established to improve equitable access, yet its effectiveness amid systemic disruptions remains understudied. This study aimed to assess the impact of these disruptions on medicine availability and affordability at Kenema Pharmacies in Lideta Sub-City.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: A mixed-methods cross-sectional design was employed. Quantitative data were collected via structured questionnaires from 257 pharmacy clients, selected through systematic random sampling. Qualitative insights were gathered through semi-structured interviews with 12 key stakeholders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOver half (57.6%) of clients faced difficulties obtaining prescribed medicines, with frequent stockouts of antibiotics, insulin, and medications for chronic diseases. Affordability was the predominant barrier, with 53.3% rating medicines as unaffordable and 51% forgoing purchases due to cost. Despite adequate physical access, supply volatility and financial constraints undermined effective utilization. Upstream procurement and distribution inefficiencies directly compromise the pharmacy’s operational performance. Supply chain disruptions at Kenema Pharmacies in Lideta Sub-City hindered access to essential medicines by causing frequent stockouts and high costs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: While Kenema Pharmacies improve geographic access, their role in ensuring reliable and affordable medicine supply is severely limited by national supply chain weaknesses. Strengthening procurement systems, inventory management, and financial protection mechanisms is essential for achieving equitable access to essential medicines in urban Ethiopia.\u003c/p\u003e","manuscriptTitle":"Impact of Supply Chain Disruptions on the Availability and Affordability of Essential Medicines at Kenema Pharmacies in Addis Ababa, Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 09:16:18","doi":"10.21203/rs.3.rs-9328438/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"291022238288769033646921161202934233610","date":"2026-05-01T18:01:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-29T16:06:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-07T13:22:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-07T00:28:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-07T00:28:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-04-05T20:43:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb070915-f325-4a94-bcd8-0901f773ae7b","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"291022238288769033646921161202934233610","date":"2026-05-01T18:01:21+00:00","index":42,"fulltext":""},{"type":"reviewersInvited","content":"30","date":"2026-04-29T16:06:05+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T09:16:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 09:16:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9328438","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9328438","identity":"rs-9328438","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}