Assessment of Essential Medicines Affordability in Primary Health Care Facilities in Southern Nigeria: “Effect of Drug Revolving Fund Performance

Assessment of Essential Medicines Affordability in Primary Health Care Facilities in Southern Nigeria: “Effect of Drug Revolving Fund Performance | 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 Assessment of Essential Medicines Affordability in Primary Health Care Facilities in Southern Nigeria: “Effect of Drug Revolving Fund Performance Frederick Ojo IFIJEH This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7629722/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Essential medicines save lives and improve health, when they are available, affordable, of assured quality and used rationally. High cost of medicines is a major barrier to accessing medicines and achieving better health outcomes. This study assessed the effect of Drug Revolving Fund performance on affordability of essential medicines in the primary health care facilities in Esan Southeast local government in southern Nigeria. Method The study was a descriptive cross-sectional study that employed both quantitative and qualitative approaches, following the standardized World Health Organization and Health Action International (WHO/HAI) methodology. Prices of 27 key essential medicines (EDs) for treatment of common diseases and 12 key essential medicines used in reproductive health were assessed in 22 primary health care facilities in Esan Southeast. The operation of Drug Revolving Fund was also explored with the use of researcher administered questionnaire to determine its performance and effect on affordability of EDs. The daily wage of the lowest paid unskilled government worker was used to gauge the affordability of essential medicines. Results The results showed that on the average the lowest paid worker would require 0.34 (representing 34%) of a day’s wage for the treatment of malaria in adults using artemisinin combination therapy (ACT), while with quinine it required 0.5 (representing 50%) of a day’s wage. Also for the treatment of childhood diseases, malaria treatment required 0.07 days wage (representing 7% of a day’s wage) using ACT while treatment with quinine required 0.43 day’s wage (representing 43% of a day’s wage). According to this study one comprehensive health centre (representing 33.3% of the total CHC) out of the three CHC had a good performance of DRF, and then two out of seventeen PHC (representing 11.8% of the total PHCs) had a good performance of DRF. None of the HP had a working DRF. Majority of the health facility had a poor performance of DRF. Health facilities with good performance of DRF also had good affordability of EDs for treatment of common diseases and vice versa. The same was true for EDs used in reproductive health. Conclusion Essential medicines for treatment of adults and child’s disease conditions were largely affordable. Alternative health financing options together with the performance of DRF had effects on affordability of essential medicines for treatment of common diseases and for reproductive health. A working Drug Revolving Fund Scheme is critical to affordable access to essential medicines in primary health care facilities. Preventive Medicine Essential medicines Affordability Primary Health Care facilities Drug Revolving Fund Esan Southeast Edo State Figures Figure 1 Introduction 1.0 Study Background Affordability is a critical determinant of access to essential medicines in primary health care, particularly in low- and middle-income countries like Nigeria 1 , 2 Although the WHO’s essential medicines framework emphasizes availability at a price individuals and communities can afford, millions still face financial barriers to accessing needed drugs. 1 In Nigeria, weak public financing for health, high out-of-pocket payments, and the absence of functional health insurance for the poor have made medicines financially inaccessible for large segments of the population. 3 The Drug Revolving Fund (DRF) was introduced through the Bamako Initiative as a sustainability mechanism to address this challenge, but it has faced criticism for placing the cost burden disproportionately on low-income patients. 4 , 5 , 6 Budgetary constraints, inflation-adjusted declines in drug funding, and procurement corruption have further worsened affordability. 7 , 8 Additionally, drug diversion and poor value-for-money procurement practices have inflated prices at the point of care, limiting the ability of PHC users to consistently access affordable treatment. 9 , 10 Without reforms to improve funding transparency, pricing regulation, and accountability, the financial accessibility of essential medicines in Nigeria remains severely compromised. 1.1 Statement of the Problem In developing countries medicines account for 25–70% of overall health care expenditure, compared to less than 10% in high income countries. Moreover, up to 90% of the population in low- and middle-income countries pay for medicines out of pocket. Therefore, medicines are unaffordable for large sectors of the global population and major burden of government. 11 Medicines are integral to effective health service delivery; however, when public health facilities experience stockouts, patients are often forced to purchase their medications at significantly higher prices from community pharmacies. This situation exacerbates financial barriers and undermines equitable access to essential medicines, particularly for vulnerable populations. 1 1.2 Justification for the Study Access to medicines to combat HIV/AIDS, malaria and tuberculosis has improved worldwide. However, the availability of affordable essential medicines is still inadequate in both public and private sectors in Nigeria. 12 Currently, in Nigeria there are large gaps in the availability of medicines in both public and private sectors, as well as wide variation in prices which render essential medicines unaffordable to poor people. In the public sector, generic medicines are only available in 38.1% of facilities, and the average cost is 250% more than the international reference price. Similarly, these medicines are available in 38.1% of private sector facilities and cost on average about 610% more than the international reference price. 12 The affordability of essential medicines and supplies at every Primary Health Care system in Nigeria is critical in the nation’s health care development. 13 This study looked at the affordability essential medicines, impact of drug revolving fund on affordability, as it relates to PHC essential drug service delivery to the inhabitant of Esan Southeast Local Government. This will serve as a baseline for further evaluation of the programme. Findings from this study would serve as a guide to essential drug programme managers in the local government and state, on access to essential medicines in primary health care. It will also help to draw conclusions and make recommendations to the local government health department for further health planning and intervention. 1.3 Research Questions Are essential medicines affordable in Primary Health Care facilities in Esan Southeast? Do these facilities have a working Drug Revolving Fund (DRF)? What impact does the DRF has on affordability of essential medicines? 1.4 Objective of the Study General Objective: To determine the access to essential medicines used in the treatment of common diseases in Esan South East Local Government. Specific Objectives: To determine the affordability of essential medicines used in Primary Health Care facilities in Esan Southeast Local Government. To determine the performance of Drug Revolving Fund in Primary Health Care Facilities in the Local Government. To assess the effect of Drug revolving Fund Performance on affordability of essential medicines. 2.0 Provision of Essential Medicines in Primary Health Care Provision of essential medicines remains a cornerstone of primary health care and universal health coverage (UHC), particularly in low- and middle-income countries (LMICs). Essential medicines are those that satisfy the priority health care needs of the population, selected based on disease prevalence, efficacy, safety, and cost-effectiveness. According to the World Health Organization (WHO, these medicines should be continuously available in functioning health systems in adequate amounts, appropriate dosage forms, with assured quality, and at prices individuals and communities can afford 14 . 2.1 Access to Essential Medicines Access to essential medicines is a key determinant of health outcomes. Despite advancements in public health, approximately 2 billion people globally still lack access to life-saving essential medicines 12 . In Sub-Saharan Africa, challenges such as poor infrastructure, underfunded health systems, and weak supply chains persist. A study in 2022 found that essential medicine availability in public facilities in LMICs ranges between 40% and 60%, with many patients paying unaffordable out-of-pocket costs 15 . Lack of essential medicines undermines trust in local health systems and compromises health professionals' ability to provide effective care. Consequently, improving access requires integrated strategies that enhance both the physical availability and financial affordability of medicines. WHO/HAI surveys from 2022–2023 confirm that medicine affordability in LMICs remains a concern, especially in the absence of subsidy mechanisms or health insurance coverage. 2.2 Drug Revolving Funds and the Bamako Initiative The Bamako Initiative, launched by WHO and UNICEF in 1987, encouraged community-based financing mechanisms like the Drug Revolving Fund (DRF) to improve access to essential medicines. The DRF model involves an initial capital investment used to procure medicines, with revenues from medicine sales used to replenish stock. Recent evaluations show that DRFs have yielded mixed results. While effective in some settings, their performance has often been constrained by governance issues, stock mismanagement, and economic instability . 14 A multi-state evaluation in Nigeria found that PHC facilities operating a DRF had a 28% reduction in stockouts compared to non-DRF sites. 14 However, affordability remained a concern in these facilities, particularly where mark-ups were not regulated. Similarly, in Kenya, DRF-supported facilities showed better availability but higher patient costs, raising concerns about equity. 13 Analysis of DRF operations in Ethiopia revealed systemic challenges such as weak replenishment systems, lack of real-time inventory tools, and insufficient capacity for financial accountability. 17 These findings reinforce the need for DRFs to be accompanied by digital supply chain tools, robust training, and periodic financial audits. 2.3 Affordability, Availability, and Utilization Recent studies reaffirm that availability alone is insufficient for access. In Ghana, a 2023 study using WHO/HAI methodology showed that 64% of essential medicines were available across public and private outlets, but most treatments for chronic diseases still cost more than a day’s wage. In Ethiopia, only 56% of surveyed essential medicines were available in public health centers, pushing patients to private pharmacies with significantly higher prices. 12 This dual challenge highlights the importance of considering affordability in DRF models. Without mechanisms to cap prices or subsidize costs for vulnerable populations, even well-stocked facilities may remain underutilized. Studies from Nigeria and Sudan consistently demonstrate that when DRFs are well-managed, with transparency, accountability, and community engagement, they can significantly improve both medicine availability and service utilization . 15 2.4 Summary and Research Gaps The literature indicates a growing body of evidence supporting the role of DRFs in improving access to essential medicines. However, significant gaps remain in understanding the comparative impact of DRFs on affordability across PHC levels. Further research is needed to assess long-term DRF performance in resource-constrained settings, especially regarding equity in urban-rural access and the effectiveness of pricing regulation mechanisms Methodology 3.1 Study Area This study was carried out in Esan Southeast Local Government. It is a Local Government area in the southern part of Nigeria. The Local Government has an estimated population of 167,721. (Based on projection of 2006 population Census estimate) 18 The inhabitants of the LGA are majorly into subsistence farming; fishing, trading and civil service The health care providers in the local government are Primary health care, secondary health care, proprietary patent medicine vendors, and traditional herbal practitioners. The structure of the primary health care available across the local government is such that there are three comprehensive health centres, seventeen primary health centres and four health posts. Each of the comprehensive health centres has a capacity of at least 30 beds, the primary health centre 10 beds. The health posts do not have beds but only offers preventive and promotive care. Majority of these centres are headed by Nurse/Midwives. The health posts are headed by Community Health Extension Workers (CHEWS) just like some of the primary health centres. Other staff includes orderlies, health attendants, labourers, security men and messengers. 3.2 Study Population The study was carried out in all functional primary health care facilities in the Local Government area. Inclusion Criteria All functional primary health care facility. Exclusion Criteria Non-functional primary health care facilities. Study Design A descriptive cross-sectional study was employed in the study. Study Duration The study took 12 months. Two months was used to correct the project proposal before submission for ethical clearance. It required three months to get ethical clearance from Irua Specialist Teaching Hospital, Research Ethics Committee. It took another three months for data collection and compilation. Data analysis and write up of the project took three months. Determination of Sample Size A total population survey was employed in the study. 3.3 Method of Data Collection 3.3.1 Tools for Data Collection The data were collected with the aid of a researcher administered checklist ( list of twenty seven (27) tracer essential medicines), and their prices collated on a data compilation sheet according to the standardized World Health Organization/ Health Action International (WHO\HAI) methodology. 19 Of the tracer essential medicines included in the survey, fourteen (14) belong to the list of core medicines included by WHO/HAI, and others were selected on the basis of being the basic ones used for the treatment of common diseases in Esan South East local government area for the year 2014/2015. For each medicine, information was collected on the price of the lowest-priced generic equivalent (LPG) found at each health facility. To measure the EDs availability, the twenty most important EDs were selected from the EDs allocated for local government drug revolving fund based on the list developed by UNICEF in collaboration with the ministry of health. The selected EDs were Category A ;( 1) ACTs, (2) Salbutamol, (3) Mebendazole /Albendazole (4) Paracetamol, (5) Ampicillin /Amoxicillin Penicillin V (6) Co-trimoxazole (7) ORS or zinc, (8) Inj hydrocortisone (9) inj Adrenalin. (10) Promethazine; Category B: ( Drugs used in reproductive health ) (1 ) Inj oxytocin (II ) Inj ergometrin (III ) inj Vitamin K ( IV ) Potassium iodide, ( V) Inj magnesium sulphate (vi ) Inj tetanus toxoid (vii ) Ferrous sulphate, (viii ) Misoprostol (ix ) Norethisterone ( x ) Tab. Vitamin C (xi) Syrup Vitamin C (xii) Folic acid. Affordability of medicine was determined by the daily wage of the lowest paid unskilled government worker, with the current minimum wage in Esan Southeast being 23,000 (116.27USD) per month as at the time of the study. [1USD = 197.8 Naira as at time of study]. A structured researcher-administered questionnaire was used to assess the management and performance of the health care facilities DRF. These included: (I) the organization of the DRF, (ii) the composition of the DRF committee, (iii) number of meetings during last year, (IV) inspections and supervisions carried out, (v) drug list, (VI) necessary equipment, (vii) drug procurement system, (viii) monitoring system for income and expenditures, (ix) reporting system, and (x) distribution of benefits. 3.4 Pretesting of Questionnaires and Checklist The checklist and questionnaire were pretested in two primary health care facilities located in a neighbouring Local Government area. 3.5 Data Analysis Data were sorted from the checklist and questionnaire and were analysed using statistical software package for scientific solution (SPSS) version 21. 20 Continuous variables such as affordability of EDs measured in terms of day’s wage were tested using ANOVA or F-test. Categorical variables such as DRF performance were categorized and their association were tested with the use of Fisher exact. P-value of 0 .05 was taken as being statistically significant. 3.5.1 Scoring System There were 21 structured questions in the questionnaire, of these only 15 of them were assigned scores according to how they contributed to the performance of DRF. Others were included for the overall good of the questionnaire. (See appendix iii for questionnaires). The scoring was done as follows with the score value of each option written in parenthesis: Question 1,2,9,13,14 & 20 were assigned a score of zero (0). Question 3: Central medical store (2) others (0), question 4: Regular (2) fairly regular (1) Irregular (0), question 5: Yes (0) No (1), question 6: Yes (2) No (0), question7: Yes (1) No (0), question 8: Yes (1) No (0), question 10 : Excellent (3) Very good (2) Good (1 ) Poor (0), question 11 : Yes (2) No (0), question 12 : (1), question 15: Excellent (3) Very good (2) Good (1 ) Poor (0), question 16–18 : (1 each), question 19 : (1), question 21 : Yes (0) No (1). The total maximum score was 23 and the score by each health facility was expressed as a percentage of the total score. Performance was rated thus; 0–39%: (Poor), 40–59%: (Fair), 60–100% (Good). 3.6 Ethical Consideration Ethical approval for this study was obtained from the Irua specialist Teaching Hospital (ISTH) ethical review committee Establishment consent: Permission for collection of data using checklist and questionnaire was sought from the Head of Local Government Authority (HOLGA) and Local Government Medical Officer of Health (MOH). Facility consent: This was obtained from the head of health facility. The management and other participants were assured that, the data that shall be collected, processed and analysed shall be treated with outmost confidentiality. Information obtained there in shall be used to draw conclusion and appropriate recommendations. Participants’ Consent: Participants were assured that information provided shall be treated with outmost confidentiality. They shall not be used in decision making that would harm their practices. 3.6 Limitation to the Study Essential medicines other than the priority drugs used for the study were missed. The minimum wage used for assessment of affordability is that of the formal sector, where many people in the Local Government do not belong to. Some health facility may give responses that are biased due to self-reporting. This was overcome by checking records to ascertain whether it correlate with the information entered in the checklist. Results The results obtained from the assessment of availability, affordability and performance of Drug Revolving fund (DRF) in primary health facilities in Esan South East Local Government are shown in figure and tables as follows. There were twenty two primary health care facilities included in the study. Of these, 13.6% are comprehensive health care (CHC), 77.3% are primary health care (PHC) and 9.1% are health post (HP) as shown in Fig. 1 . Affordability of Essential Medicines The mean days’ wage for treatment of malarial in adults in the health care facilities using SP was 0.87 (SD ± 0.05) at the CHC, at the PHC it was 0.10(SD ± 0.04) and at the HP it was 0.13(SD ± 0.0). The mean day’s wage required for treatment of malarial in adults in the facilities using ACT was 0.30 (SD ± 0.15) at the CHC, it was 0.34(SD ± 0.10) at the PHC and 0.39 (SD ± 0.0) at the HP. The mean day’s wage required for treatment of malarial in adults using Quinine was 0.44 (SD ± 0.09) at the CHC, it was 0.54(SD ± 0.21) at the PHC and 0.31(SD ± 0.25) at the HP. It was cheaper to treat malarial using ACT than Quinine across the health facility, though SP was more affordable compared to ACT and Quinine. The day’s wages required for each treatment option according to facility type varies only marginally except for treatment with SP where it was lower at the PHC. The mean day’s wage for treatment of Pneumonia in the health facility using amoxicillin 500mg was 0.20 (± 0.07) at the CHC, it was 0.24(SD ± 0.14) at the PHC and 0.27(SD ± 0.0) at the HP. However, with treatment using erythromycin 500mg it was 0.50 (SD ± 0.10) at the CHC, it was 0.75(SD ± 0.24) at the PHC and 0.78(SD ± 0.0) at the HP. Treatment of pneumonia was more affordable using amoxicillin than erythromycin, but it was more affordable at the CHC than at the PHC and HP. The mean day’s wage for treatment of diarrhoea using Metronidazole 200mg was 0.07 (SD ± 0.122) at the CHC, it was 0.09 (SD ± 0.26) at the PHC and 0.11 (SD ± 0.0) at the HP. Treatment with Tetracycline was 0.10 (SD ± 0.04) at the CHC, it was 0.12(SD ± 0.03) at the PHC and 0.16 (SD ± 0.0) at the HP. Treatment with Tetracycline and Metronidazole vary only marginally according to type of facility being more affordable at the CHC, followed by PHC then the HP. Also, it was cheaper to treat diarrhoea with Metronidazole200mg than with tetracycline 250mg. The mean day’s wage for treatment of anaemia using Fersolate across all the health facilities was 0.12 (SD ± 0.05) except at the PHC where it was marginally higher (required 0.14 day’s wage) while treatment using folic acid was 0.04 (SD ± 0.0) day’s wage across all the health facilities. The mean day’s wage for treatment of hypertension in the health facilities using methyl dopa was 0.27 (SD ± 0.08) while using Nifedipine 20mg it was 0.09 (SD ± 0.02) except at the PHC where it was higher. The treatment of hypertension was the same in the different types of facility but vary with the different treatment options. It was more affordable to manage hypertension with Nifedipine 20mg than with methyldopa 250mg. The mean day’s wage for treatment of rheumatic pains using paracetamol 500mg was 0.04 (SD ± 0.01) at the CHC and PHC and 0.22 (SD ± 0.01) at the HP, While using ibuprofen 200mg it was marginally different across the different facility type being 0.07 (SD ± 0, 06) at the CHC, 0.06 (SD ± 0.04) at the PHC and 0.04 (SD ± 0.0) at the HP. The variation in the treatment cost using paracetamol according to type of facility was significant (p-value < 0.05) as it was far higher at the HP. The treatment of other respiratory tract infection (ARI) with Salbutamol varies only marginally with treatment cost higher in CHC (required 0.09 day’s wage), followed by PHC (required 0.07 day’s wage) and then HP (which required 0.06 day’s wage). However, this difference was not statistically significant. The mean day’s wage for the treatment of helminthiasis with Albendazole 400mg was 0.06 (about 6% of a day’s wage). This was the same across all the health facilities. The treatment of soft tissue diseases was more affordable in the CHC (required 0.19 day’s wage) followed by PHC (required 0.31 day’s wage) and then HP which required 0.37 day’s wage. However, this difference was not significant (p-value = 0.272). Affordability of Treatment for children disease conditions The mean day’s wage required for treatment of malarial for paediatrics using ACT across facilities was 0.06 (SD ± 0.01) except at the CHC where it marginally higher (0.07). Treatment of malarial using Quinine was more affordable at the CHC (required 0.37) and PHC (required 0.43) day’s wages compared to the HP which required 0.46 day’s wage. However, treatment of malarial in children using ACT was more affordable at the health facilities compared to Quinine. The mean day’s wage required for treatment of Pneumonia in children using Amoxicillin was 0.19 (SD ± 0.0) at the CHC, 0.21 (SD ± 0.03) at the PHC and 0.26 (SD ± 0.0) at the HP. Treatment with Erythromycin was 0.46 (SD ± 0.28) day’s wage at the CHC, 0.38(SD ± 0.19) at the PHC and 0.33 (SD ± 0.0) at the HP. Treatment of Pneumonia in children using Amoxicillin was more affordable at the CHC and less at the HP. However with Erythromycin it was more affordable at the HP and less at the CHC. The variation in the cost of treatment using Amoxicillin according to facility type was significant (p < 0.05) due to higher cost recorded at the HP. Treatment of diarrhoea required a mean day’s wage of 0.18(SD ± 0.02) at the CHC and PHC and 0.19 at the HP using Metronidazole while with ORS it was 0.28 (SD ± 0.08) at the CHC and PHC then 0.33(SD ± 0.0) at the HP. Treatment of childhood diarrhoea was more affordable using Metronidazole compared to ORS with zinc. Affordability of treatment according to treatment option was almost the same across facility type except with ORS and zinc was treatment was less affordable at the HP. The mean day’s wage for treatment of skin disease with Clotrimazole was 0.19 while that with Povidone iodine was 0.39. The mean day’s wage for treatment of anaemia in paediatrics using Ferrous sulphate was 0.19 (SD ± 0.0) at the CHC and HP, and 0.20(SD ± 0.05) at the PHC. Treatment with Albendazole required 0.06 (SD ± 0.0) mean day’s wage at the CHC and HP, and 0.08 (SD ± 0.06) at the PHC. Treatment of childhood anaemia with Fersolate and Albendazole were almost the same in all the facility but marginally higher at the PHC. The mean day’s wage for treatment of typhoid in children was 0.18 (SD ± 0.02) at the CHC, and 0.19 at the HP using Chloramphenicol and Co-trimoxazole. Treatment of typhoid in children was more affordable in CHC (required 0.18 day’s wage) and less at the PHC (required 0.20 day’s wage). Treatment with Co-trimoxazole was more affordable at the PHC (required 0.17 day’s wage) and less at the HP (required 0.19 day’s wage.) One out of the three CHC had a good DRF performance, one had a fair DRF performance and one had a poor DRF performance. Out of the seventeen PHC studied, two had a good DRF performance, three had a fair DRF performance and twelve had a poor DRF performance. The two HP had a poor DRF performance. The performance of DRF was not dependent on the type of health facility (p-value = 0.585). Discussion This study looked the access to essential medicines in the primary health care facilities in Esan South East; to provide relevant information for planning effective primary health care for the community. Specifically, the study sought to determine the affordability of essential medicines and Drug Revolving Fund Performance, to influence essential drug programme managers and redirect health policy makers to factors that affect pharmaceutical care provisions. Affordability of Essential Medicines Provision of promotive, preventive, curative and rehabilitative health services require regular availability of relevant medicines of proven safety, efficacy and quality at an affordable price. 21 High cost of medicines is a major barrier to accessing medicines and achieving better health outcomes. 22 , 23 Affordability in this study was calculated in terms of the number of days the lowest paid unskilled government worker would have to work to pay for one treatment course for an acute condition or one month’s treatment for a chronic condition. At the time of the study, the lowest paid unskilled government worker in Esan southeast earned seven hundred and seventy naira ( 770) per day (equivalent to 3.88USD per day) as of July 2015. On the average the lowest paid worker would require 0.34(representing 34%) of a day’s wage for the treatment of malaria in adults using artemisinin combination therapy, while with quinine it required 0.5 (representing 50%) of a day’s wage. Also for the treatment of childhood diseases, malaria treatment required 0.07 days wage (representing 7% of a day’s wage) using ACT while treatment with quinine required 0.43 day’s wage (representing 43% of a day’s wage).The cost of treatment differed with different treatment options for a particular disease condition in both adults and children per facility. It was cheaper to manage malaria using ACT than quinine in both adults and children. However the costs of treatment of disease conditions with respect to treatment options were almost the same in the different types of facility (i.e. CHC, PHC and HP).The mean day’s wage for treatment of adults diseases across facility was 0.21 (SD ± 0.08) representing 21% of a day’s wage. The mean day’s wage for the treatment of childhood diseases was 0.23 (SD ± 0.07) representing 23% of a day’s wage. In a study conducted in Ghana an average of 1.67 day’s wage (representing167% of a day’s wage) was needed to treat adult’s disease condition and 0.78 day’s wages (representing 78% of a day’s wage) for a child’s disease condition. In the same survey a complete course of treatment of malaria required 1.3 day’s wage (representing130% of a day’s wage). A similar study carried out in Sudan showed an average of 0.62 day’s wage (representing 62% of a day’s wage) for treatment of malaria. 24 Even though the cost of treatment varies marginally according to type of facility in the management of some ailments, affordability was not crucial as no treatment option required more than a day’s wage for treatment. This may have been due to subsidy applied to the medicines supplied to the primary health facilities in the LGA. This may impact positively on patients’ health care seeking behaviour to the primary health care facilities in the LGA. Performance of Drug Revolving Fund (DRF) One of the major indices of the performance of the primary healthcare delivery remains improved access to essential drugs. The more commonly used mechanisms to address inequities in rural access to medicines was the establishment of drug revolving funds, whereby a capital investment allows for the initial purchase of medicines and revenues from medicine sales or user fees are used to replenish stock. Sustainable and successful schemes have been described across Africa. 25, 26,27 According to this study one out of the three CHC (representing 33.3% of the total CHC) had a good performance of DRF, and then two out of seventeen PHC (representing11.8%) had a good performance of DRF. None of the HP had a working DRF. Majority of the health facilities (68.2%) had a poor performance of DRF [shown in Table 18 ]. This was due to non-operational DRF in most of the health care facilities. Conclusions Essential medicines for treatment of common diseases and for reproductive health in 2015 in primary health facilities in Esan Southeast L.G.A were largely affordable. On the average no treatment option required more than 50% of a day’s wage for treatment. The performance of DRF varied according to facility type, affordability was not crucial as no treatment option required more than a day’s wage for treatment. This may have been due to subsidy applied to the medicines supplied to the primary health facilities in the LGA had a positive influence on the affordability of essential medicines for treatment of common diseases and for reproductive health. A working Drug Revolving Fund Scheme is critical to health commodity security in primary health care facilities. Recommendations The study recommends that: 1. Revision of different financing options such as Drug Revolving Fund and community health insurance scheme need to be implemented. 2. There is need for Local Government Health Authority to ensure availability of a robust and functional DRF in all health facilities in the LGA. Declarations Ethics Approval and Consent to Participate: Ethical approval for this study was obtained from the Irua specialist Teaching Hospital (ISTH) ethical review committee Consent for Publication: Not applicable. Clinical trial number: Not applicable Availability of Data and Materials: The data supporting this study's findings is provided as an attachment to the submission. Competing Interests: The authors declare that they have no competing interests. Funding: No external funding was received for this study. Authors' Contributions Ifijeh Frederick conceived the study, led the manuscript writing, and coordinated data interpretation. Bravo Otohabru contributed to the contextual interpretation of health facility operations and policy alignment. Ejiyere Harrison. O conducted the statistical analysis and contributed to the interpretation of the data. All authors read, reviewed and approved of the final manuscript. Acknowledgements: Ifijeh Frederick appreciates the support of the Edo State Ministry of Health, Primary Health care Development Agency, Local Government civil Service commission and medical officer of Health for granting approvals for this research. Authors' Information: Not applicable. References World Health Organization (2023) Universal access to essential medicines: 2023 global status report. WHO, Geneva Kemp A, Karim A, Najmi A, Ratanawijitrasin S, Pécoul B, Moeti M, Kieny MP (2022) Availability, affordability, and accessibility of essential medicines in 13 low-income countries. BMJ Global Health 7(9):e009231. https://doi.org/10.1136/bmjgh-2022-009231 Umeh C, Nwokoro I, Yusuf B (2022) Out-of-pocket cost and affordability of essential medicines in urban Nigeria. PLOS Global Public Health, 2(4), e0000324 World Health Organization (1988) The use of essential drugs: Report of the WHO Expert Committee (Technical Report Series No. 770). Geneva: World Health Organization UNICEF (1987) The state of the world's children 1987. Oxford University Press, New York MSH & NPSCMP (2023) Evaluation of Drug Revolving Fund Implementation in PHCs Across Nigeria. Federal Ministry of Health, Abuja Chukwuani CM, Parakoyi DB, Ugbene EO (2006) A baseline survey of the Primary Health Care system in Nigeria. Health Policy 77(2):182–194 Federal Ministry of Health (2020) National Health Accounts: Summary Report. Abuja, Nigeria Onwujekwe O, Aloysius O, Chinyere M, Eleanor H, Hyacinth I, Pamela Adaobi OP, Agwu P, Uche SO, Dina B (2019) Corruption in the Nigerian health sector: A systematic review. Public Health Ethics 12(1):30–45 Olanrewaju A, Mbachu C, Uche O, Onwujekwe. IH O (2022) Health financing and essential medicine access in Nigeria. PLOS Global Public Health, 2(3), e0000217 Watal J Access to Essential Medicines in Developing Countries: Does the WTO TRIPS agreement hinder it. Available at http://www.iatp.org/files/accessto_essential_medicines_in_ developing_co.pdf . {Accessed on 5th July 2014} Lufesi NN, Andrew M, Aursnes I (2007) Deficient supplies of drugs for life threatening diseases in an African community. Biomed Cent Health Serv Res 7:86 Federal Ministry of Healthcare Development Agency (2013) Nigeria Draft Essential childhood medicines scale- up plan. March 30th Bigdeli M, Shuey D, Ketsouvannansane B, Douangdeuane B (2004) Operational research on Village Drug Revolving Funds in Lao PDR. Vientiane: World Health Organization & Food and Drug Department, Ministry of Health, Lao PDR. ;28:692–704 Federal Ministry of Health (1990) Annual statistical report. Federal Ministry of Health, Khartoum- Sudan Mazi SA Challenges of making quality essential drugs and supply available for primary health care services in Nigeria. 2008[. Cited 2013 Nov.] Available from: apps.who.int/../S183298en.pdf Watal J Access to Essential Medicines in Developing Countries: Does the WTO TRIPS agreement hinder it. Available at http://www.iatp.org/files/access to essential_medicines_in_ developing_co.pdf. {Accessed on 5th July 2014} Federal republic of Nigeria official gazette (2009) Vol 2 Abuja – 2nd Febr 96 World Health Organisation and Health Action International (2008) Measuring medicine prices, availability, affordability and price components. Manage Sci Health 2:84 Inc SPSS., Chicago (2013) window version 21.0. Armonk. IBM corp, NY Gilson L, Kitange H, Teuscher T (1993) Assessment of process quality in Tanzanian primary care. Health Policy 26:119–139 Van der Geest S (2000) User fees and drugs: what did the health reforms in Zambia achieve? Health Policy Plann 15(1):59–65 Everard M (2002) Access to medicines in low-income countries. Int J risk Saf Med 15:137–149 Cheraghali AM, Nikfar S, Behmanesh Y, Rahimi V, Habibipour F, Tirdad R (2004) Evaluation of availability, accessibility and prescribing pattern of medicines in the Islamic Republic of Iran. East Mediterr Health J 10(3):406–415 Uzochukwu BSC, Onwujekwe O, E and, Akpala C (2002) Effect of the Bamako-Initiative drug revolving funds availability and rational use of essential drugs in primary health care facilities in south-east Nigeria. Health Policy Plann 17:4: 378–383 Waning B, Maddix, Tripodis Y, Laing R, Leufkens HG, Gokhale M (2009) Towards equitable access to medicines for the rural poor: initiative triggers price competition in Kyrgyzstan. Int J Equity Health 8:43 Ali GKM (2009) Accessibility of medicines and primary health care: The impact of the revolving drug fund in Khartoum State. Afr J Pharm Pharmacol 3:70–77 Tables Tables 3 to 18 are available in the Supplementary Files section. Appendix Appendix iii is not available with this version. Additional Declarations The authors declare no competing interests. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted 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. 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07:49:43","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101710,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7629722/v1/c007e3a3e3842be66953b1da.html"},{"id":91960937,"identity":"ad956f3d-36f8-4419-bbb0-18ec3a8cf74d","added_by":"auto","created_at":"2025-09-23 07:49:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15436,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage distribution of types of Primary Health Facility in Esan South East LGA.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7629722/v1/d2feb06bc661ca163d8b6523.png"},{"id":91962669,"identity":"14fee96c-d173-4e79-8e0e-537be35da355","added_by":"auto","created_at":"2025-09-23 07:57:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":776915,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7629722/v1/2342517b-aab2-41c3-b987-aaa57fc38549.pdf"},{"id":91960938,"identity":"2781fc60-c0a5-4cc3-9072-5443298e5409","added_by":"auto","created_at":"2025-09-23 07:49:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20167,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7629722/v1/dd1af0e905b7ac32c3debc1c.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAssessment of Essential Medicines Affordability in Primary Health Care Facilities in Southern Nigeria: “Effect of Drug Revolving Fund Performance\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\n\u003ch3\u003e1.0 Study Background\u003c/h3\u003e\n\u003cp\u003eAffordability is a critical determinant of access to essential medicines in primary health care, particularly in low- and middle-income countries like Nigeria\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Although the WHO\u0026rsquo;s essential medicines framework emphasizes availability at a price individuals and communities can afford, millions still face financial barriers to accessing needed drugs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In Nigeria, weak public financing for health, high out-of-pocket payments, and the absence of functional health insurance for the poor have made medicines financially inaccessible for large segments of the population.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The Drug Revolving Fund (DRF) was introduced through the Bamako Initiative as a sustainability mechanism to address this challenge, but it has faced criticism for placing the cost burden disproportionately on low-income patients.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Budgetary constraints, inflation-adjusted declines in drug funding, and procurement corruption have further worsened affordability.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Additionally, drug diversion and poor value-for-money procurement practices have inflated prices at the point of care, limiting the ability of PHC users to consistently access affordable treatment.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Without reforms to improve funding transparency, pricing regulation, and accountability, the financial accessibility of essential medicines in Nigeria remains severely compromised.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Statement of the Problem\u003c/h2\u003e\u003cp\u003eIn developing countries medicines account for 25\u0026ndash;70% of overall health care expenditure, compared to less than 10% in high income countries. Moreover, up to 90% of the population in low- and middle-income countries pay for medicines out of pocket. Therefore, medicines are unaffordable for large sectors of the global population and major burden of government.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMedicines are integral to effective health service delivery; however, when public health facilities experience stockouts, patients are often forced to purchase their medications at significantly higher prices from community pharmacies. This situation exacerbates financial barriers and undermines equitable access to essential medicines, particularly for vulnerable populations.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Justification for the Study\u003c/h2\u003e\u003cp\u003eAccess to medicines to combat HIV/AIDS, malaria and tuberculosis has improved worldwide. However, the availability of affordable essential medicines is still inadequate in both public and private sectors in Nigeria.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCurrently, in Nigeria there are large gaps in the availability of medicines in both public and private sectors, as well as wide variation in prices which render essential medicines unaffordable to poor people. In the public sector, generic medicines are only available in 38.1% of facilities, and the average cost is 250% more than the international reference price. Similarly, these medicines are available in 38.1% of private sector facilities and cost on average about 610% more than the international reference price. \u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe affordability of essential medicines and supplies at every Primary Health Care system in Nigeria is critical in the nation\u0026rsquo;s health care development. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study looked at the affordability essential medicines, impact of drug revolving fund on affordability, as it relates to PHC essential drug service delivery to the inhabitant of Esan Southeast Local Government. This will serve as a baseline for further evaluation of the programme. Findings from this study would serve as a guide to essential drug programme managers in the local government and state, on access to essential medicines in primary health care. It will also help to draw conclusions and make recommendations to the local government health department for further health planning and intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003e1.3 Research Questions\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAre essential medicines affordable in Primary Health Care facilities in Esan Southeast?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDo these facilities have a working Drug Revolving Fund (DRF)?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat impact does the DRF has on affordability of essential medicines?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.4 Objective of the Study\u003c/h2\u003e\u003cp\u003eGeneral Objective:\u003c/p\u003e\u003cp\u003eTo determine the access to essential medicines used in the treatment of common diseases in Esan South East Local Government.\u003c/p\u003e\u003cp\u003eSpecific Objectives:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo determine the affordability of essential medicines used in Primary Health Care facilities in Esan Southeast Local Government.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo determine the performance of Drug Revolving Fund in Primary Health Care Facilities in the Local Government.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo assess the effect of Drug revolving Fund Performance on affordability of essential medicines.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e2.0 Provision of Essential Medicines in Primary Health Care\u003c/h3\u003e\n\u003cp\u003eProvision of essential medicines remains a cornerstone of primary health care and universal health coverage (UHC), particularly in low- and middle-income countries (LMICs). Essential medicines are those that satisfy the priority health care needs of the population, selected based on disease prevalence, efficacy, safety, and cost-effectiveness. According to the World Health Organization (WHO, these medicines should be continuously available in functioning health systems in adequate amounts, appropriate dosage forms, with assured quality, and at prices individuals and communities can afford \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Access to Essential Medicines\u003c/h2\u003e\u003cp\u003eAccess to essential medicines is a key determinant of health outcomes. Despite advancements in public health, approximately 2\u0026nbsp;billion people globally still lack access to life-saving essential medicines \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In Sub-Saharan Africa, challenges such as poor infrastructure, underfunded health systems, and weak supply chains persist. A study in 2022 found that essential medicine availability in public facilities in LMICs ranges between 40% and 60%, with many patients paying unaffordable out-of-pocket costs \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eLack of essential medicines undermines trust in local health systems and compromises health professionals' ability to provide effective care. Consequently, improving access requires integrated strategies that enhance both the physical availability and financial affordability of medicines. WHO/HAI surveys from 2022\u0026ndash;2023 confirm that medicine affordability in LMICs remains a concern, especially in the absence of subsidy mechanisms or health insurance coverage.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Drug Revolving Funds and the Bamako Initiative\u003c/h2\u003e\u003cp\u003eThe Bamako Initiative, launched by WHO and UNICEF in 1987, encouraged community-based financing mechanisms like the Drug Revolving Fund (DRF) to improve access to essential medicines. The DRF model involves an initial capital investment used to procure medicines, with revenues from medicine sales used to replenish stock. Recent evaluations show that DRFs have yielded mixed results. While effective in some settings, their performance has often been constrained by governance issues, stock mismanagement, and economic instability .\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA multi-state evaluation in Nigeria found that PHC facilities operating a DRF had a 28% reduction in stockouts compared to non-DRF sites.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e However, affordability remained a concern in these facilities, particularly where mark-ups were not regulated. Similarly, in Kenya, DRF-supported facilities showed better availability but higher patient costs, raising concerns about equity.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAnalysis of DRF operations in Ethiopia revealed systemic challenges such as weak replenishment systems, lack of real-time inventory tools, and insufficient capacity for financial accountability.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These findings reinforce the need for DRFs to be accompanied by digital supply chain tools, robust training, and periodic financial audits.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Affordability, Availability, and Utilization\u003c/h2\u003e\u003cp\u003eRecent studies reaffirm that availability alone is insufficient for access. In Ghana, a 2023 study using WHO/HAI methodology showed that 64% of essential medicines were available across public and private outlets, but most treatments for chronic diseases still cost more than a day\u0026rsquo;s wage. In Ethiopia, only 56% of surveyed essential medicines were available in public health centers, pushing patients to private pharmacies with significantly higher prices.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis dual challenge highlights the importance of considering affordability in DRF models. Without mechanisms to cap prices or subsidize costs for vulnerable populations, even well-stocked facilities may remain underutilized. Studies from Nigeria and Sudan consistently demonstrate that when DRFs are well-managed, with transparency, accountability, and community engagement, they can significantly improve both medicine availability and service utilization .\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Summary and Research Gaps\u003c/h2\u003e\u003cp\u003eThe literature indicates a growing body of evidence supporting the role of DRFs in improving access to essential medicines. However, significant gaps remain in understanding the comparative impact of DRFs on affordability across PHC levels. Further research is needed to assess long-term DRF performance in resource-constrained settings, especially regarding equity in urban-rural access and the effectiveness of pricing regulation mechanisms\u003c/p\u003e\u003c/div\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Study Area\u003c/h2\u003e\u003cp\u003eThis study was carried out in Esan Southeast Local Government. It is a Local Government area in the southern part of Nigeria. The Local Government has an estimated population of 167,721. (Based on projection of 2006 population Census estimate)\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003eThe inhabitants of the LGA are majorly into subsistence farming; fishing, trading and civil service\u003c/p\u003e\u003cp\u003eThe health care providers in the local government are Primary health care, secondary health care, proprietary patent medicine vendors, and traditional herbal practitioners. The structure of the primary health care available across the local government is such that there are three comprehensive health centres, seventeen primary health centres and four health posts. Each of the comprehensive health centres has a capacity of at least 30 beds, the primary health centre 10 beds. The health posts do not have beds but only offers preventive and promotive care. Majority of these centres are headed by Nurse/Midwives. The health posts are headed by Community Health Extension Workers (CHEWS) just like some of the primary health centres. Other staff includes orderlies, health attendants, labourers, security men and messengers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Study Population\u003c/h2\u003e\u003cp\u003eThe study was carried out in all functional primary health care facilities in the Local Government area.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003cp\u003eAll functional primary health care facility.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003cp\u003eNon-functional primary health care facilities.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003cp\u003eA descriptive cross-sectional study was employed in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy Duration\u003c/strong\u003e\u003cp\u003eThe study took 12 months. Two months was used to correct the project proposal before submission for ethical clearance. It required three months to get ethical clearance from Irua Specialist Teaching Hospital, Research Ethics Committee. It took another three months for data collection and compilation. Data analysis and write up of the project took three months.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDetermination of Sample Size\u003c/strong\u003e\u003cp\u003eA total population survey was employed in the study.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Method of Data Collection\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 Tools for Data Collection\u003c/h2\u003e\u003cp\u003eThe data were collected with the aid of a researcher administered checklist ( list of twenty seven (27) tracer essential medicines), and their prices collated on a data compilation sheet according to the standardized World Health Organization/ Health Action International (WHO\\HAI) methodology.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Of the tracer essential medicines included in the survey, fourteen (14) belong to the list of core medicines included by WHO/HAI, and others were selected on the basis of being the basic ones used for the treatment of common diseases in Esan South East local government area for the year 2014/2015. For each medicine, information was collected on the price of the lowest-priced generic equivalent (LPG) found at each health facility. To measure the EDs availability, the twenty most important EDs were selected from the EDs allocated for local government drug revolving fund based on the list developed by UNICEF in collaboration with the ministry of health. The selected EDs were Category A ;( 1) ACTs, (2) Salbutamol, (3) Mebendazole /Albendazole (4) Paracetamol, (5) Ampicillin /Amoxicillin Penicillin V (6) Co-trimoxazole (7) ORS or zinc, (8) Inj hydrocortisone (9) inj Adrenalin. (10) Promethazine; Category B: ( Drugs used in reproductive health ) (1 ) Inj oxytocin (II ) Inj ergometrin (III ) inj Vitamin K ( IV ) Potassium iodide, ( V) Inj magnesium sulphate (vi ) Inj tetanus toxoid (vii ) Ferrous sulphate, (viii ) Misoprostol (ix ) Norethisterone ( x ) Tab. Vitamin C (xi) Syrup Vitamin C (xii) Folic acid.\u003c/p\u003e\u003cp\u003eAffordability of medicine was determined by the daily wage of the lowest paid unskilled government worker, with the current minimum wage in Esan Southeast being 23,000 (116.27USD) per month as at the time of the study. [1USD\u0026thinsp;=\u0026thinsp;197.8 Naira as at time of study].\u003c/p\u003e\u003cp\u003eA structured researcher-administered questionnaire was used to assess the management and performance of the health care facilities DRF. These included: (I) the organization of the DRF, (ii) the composition of the DRF committee, (iii) number of meetings during last year, (IV) inspections and supervisions carried out, (v) drug list, (VI) necessary equipment, (vii) drug procurement system, (viii) monitoring system for income and expenditures, (ix) reporting system, and (x) distribution of benefits.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e3.4 Pretesting of Questionnaires and Checklist\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eThe checklist and questionnaire were pretested in two primary health care facilities located in a neighbouring Local Government area.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Data Analysis\u003c/h2\u003e\u003cp\u003eData were sorted from the checklist and questionnaire and were analysed using statistical software package for scientific solution (SPSS) version 21.\u003csup\u003e20\u003c/sup\u003e Continuous variables such as affordability of EDs measured in terms of day\u0026rsquo;s wage were tested using ANOVA or F-test. Categorical variables such as DRF performance were categorized and their association were tested with the use of Fisher exact. P-value of 0 .05 was taken as being statistically significant.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003e3.5.1 Scoring System\u003c/h2\u003e\u003cp\u003eThere were 21 structured questions in the questionnaire, of these only 15 of them were assigned scores according to how they contributed to the performance of DRF. Others were included for the overall good of the questionnaire. (See appendix iii for questionnaires). The scoring was done as follows with the score value of each option written in parenthesis:\u003c/p\u003e\u003cp\u003eQuestion 1,2,9,13,14 \u0026amp; 20 were assigned a score of zero (0). Question 3: Central medical store (2) others (0), question 4: Regular (2) fairly regular (1) Irregular (0), question 5: Yes (0) No (1), question 6: Yes (2) No (0), question7: Yes (1) No (0), question 8: Yes (1) No (0), question 10 : Excellent (3) Very good (2) Good (1 ) Poor (0), question 11 : Yes (2) No (0), question 12 : (1), question 15: Excellent (3) Very good (2) Good (1 ) Poor (0), question 16\u0026ndash;18 : (1 each), question 19 : (1), question 21 : Yes (0) No (1). The total maximum score was 23 and the score by each health facility was expressed as a percentage of the total score. Performance was rated thus; 0\u0026ndash;39%: (Poor), 40\u0026ndash;59%: (Fair), 60\u0026ndash;100% (Good).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Ethical Consideration\u003c/h2\u003e\u003cp\u003eEthical approval for this study was obtained from the Irua specialist Teaching Hospital (ISTH) ethical review committee\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEstablishment consent:\u003c/h3\u003e\n\u003cp\u003ePermission for collection of data using checklist and questionnaire was sought from the Head of Local Government Authority (HOLGA) and Local Government Medical Officer of Health (MOH).\u003c/p\u003e\n\u003ch3\u003eFacility consent:\u003c/h3\u003e\n\u003cp\u003eThis was obtained from the head of health facility.\u003c/p\u003e\u003cp\u003eThe management and other participants were assured that, the data that shall be collected, processed and analysed shall be treated with outmost confidentiality. Information obtained there in shall be used to draw conclusion and appropriate recommendations.\u003c/p\u003e\n\u003ch3\u003eParticipants’ Consent:\u003c/h3\u003e\n\u003cp\u003eParticipants were assured that information provided shall be treated with outmost confidentiality. They shall not be used in decision making that would harm their practices.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.6 Limitation to the Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEssential medicines other than the priority drugs used for the study were missed.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe minimum wage used for assessment of affordability is that of the formal sector, where many people in the Local Government do not belong to.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSome health facility may give responses that are biased due to self-reporting. This was overcome by checking records to ascertain whether it correlate with the information entered in the checklist.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results obtained from the assessment of availability, affordability and performance of Drug Revolving fund (DRF) in primary health facilities in Esan South East Local Government are shown in figure and tables as follows.\u003c/p\u003e\n\u003cp\u003eThere were twenty two primary health care facilities included in the study. Of these, 13.6% are comprehensive health care (CHC), 77.3% are primary health care (PHC) and 9.1% are health post (HP) as shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eAffordability of Essential Medicines\u003c/h3\u003e\n\u003cp\u003eThe mean days\u0026rsquo; wage for treatment of malarial in adults in the health care facilities using SP was 0.87 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05) at the CHC, at the PHC it was 0.10(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04) and at the HP it was 0.13(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0). The mean day\u0026rsquo;s wage required for treatment of malarial in adults in the facilities using ACT was 0.30 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15) at the CHC, it was 0.34(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10) at the PHC and 0.39 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. The mean day\u0026rsquo;s wage required for treatment of malarial in adults using Quinine was 0.44 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09) at the CHC, it was 0.54(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21) at the PHC and 0.31(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25) at the HP. It was cheaper to treat malarial using ACT than Quinine across the health facility, though SP was more affordable compared to ACT and Quinine. The day\u0026rsquo;s wages required for each treatment option according to facility type varies only marginally except for treatment with SP where it was lower at the PHC.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of Pneumonia in the health facility using amoxicillin 500mg was 0.20 (\u0026plusmn;\u0026thinsp;0.07) at the CHC, it was 0.24(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14) at the PHC and 0.27(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. However, with treatment using erythromycin 500mg it was 0.50 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10) at the CHC, it was 0.75(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24) at the PHC and 0.78(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. Treatment of pneumonia was more affordable using amoxicillin than erythromycin, but it was more affordable at the CHC than at the PHC and HP.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of diarrhoea using Metronidazole 200mg was 0.07 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.122) at the CHC, it was 0.09 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26) at the PHC and 0.11 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. Treatment with Tetracycline was 0.10 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04) at the CHC, it was 0.12(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03) at the PHC and 0.16 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. Treatment with Tetracycline and Metronidazole vary only marginally according to type of facility being more affordable at the CHC, followed by PHC then the HP. Also, it was cheaper to treat diarrhoea with Metronidazole200mg than with tetracycline 250mg.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of anaemia using Fersolate across all the health facilities was 0.12 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05) except at the PHC where it was marginally higher (required 0.14 day\u0026rsquo;s wage) while treatment using folic acid was 0.04 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) day\u0026rsquo;s wage across all the health facilities.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of hypertension in the health facilities using methyl dopa was 0.27 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08) while using Nifedipine 20mg it was 0.09 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02) except at the PHC where it was higher. The treatment of hypertension was the same in the different types of facility but vary with the different treatment options. It was more affordable to manage hypertension with Nifedipine 20mg than with methyldopa 250mg.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of rheumatic pains using paracetamol 500mg was 0.04 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01) at the CHC and PHC and 0.22 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01) at the HP, While using ibuprofen 200mg it was marginally different across the different facility type being 0.07 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0, 06) at the CHC, 0.06 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04) at the PHC and 0.04 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. The variation in the treatment cost using paracetamol according to type of facility was significant (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05) as it was far higher at the HP.\u003c/p\u003e\n\u003cp\u003eThe treatment of other respiratory tract infection (ARI) with Salbutamol varies only marginally with treatment cost higher in CHC (required 0.09 day\u0026rsquo;s wage), followed by PHC (required 0.07 day\u0026rsquo;s wage) and then HP (which required 0.06 day\u0026rsquo;s wage). However, this difference was not statistically significant.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for the treatment of helminthiasis with Albendazole 400mg was 0.06 (about 6% of a day\u0026rsquo;s wage). This was the same across all the health facilities.\u003c/p\u003e\n\u003cp\u003eThe treatment of soft tissue diseases was more affordable in the CHC (required 0.19 day\u0026rsquo;s wage) followed by PHC (required 0.31 day\u0026rsquo;s wage) and then HP which required 0.37 day\u0026rsquo;s wage. However, this difference was not significant (p-value\u0026thinsp;=\u0026thinsp;0.272).\u003c/p\u003e\n\u003ch3\u003eAffordability of Treatment for children disease conditions\u003c/h3\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage required for treatment of malarial for paediatrics using ACT across facilities was 0.06 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01) except at the CHC where it marginally higher (0.07). Treatment of malarial using Quinine was more affordable at the CHC (required 0.37) and PHC (required 0.43) day\u0026rsquo;s wages compared to the HP which required 0.46 day\u0026rsquo;s wage. However, treatment of malarial in children using ACT was more affordable at the health facilities compared to Quinine.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage required for treatment of Pneumonia in children using Amoxicillin was 0.19 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the CHC, 0.21 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03) at the PHC and 0.26 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. Treatment with Erythromycin was 0.46 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28) day\u0026rsquo;s wage at the CHC, 0.38(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19) at the PHC and 0.33 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. Treatment of Pneumonia in children using Amoxicillin was more affordable at the CHC and less at the HP. However with Erythromycin it was more affordable at the HP and less at the CHC. The variation in the cost of treatment using Amoxicillin according to facility type was significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) due to higher cost recorded at the HP.\u003c/p\u003e\n\u003cp\u003eTreatment of diarrhoea required a mean day\u0026rsquo;s wage of 0.18(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02) at the CHC and PHC and 0.19 at the HP using Metronidazole while with ORS it was 0.28 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08) at the CHC and PHC then 0.33(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the HP. Treatment of childhood diarrhoea was more affordable using Metronidazole compared to ORS with zinc. Affordability of treatment according to treatment option was almost the same across facility type except with ORS and zinc was treatment was less affordable at the HP.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of skin disease with Clotrimazole was 0.19 while that with Povidone iodine was 0.39.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of anaemia in paediatrics using Ferrous sulphate was 0.19 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) at the CHC and HP, and 0.20(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05) at the PHC. Treatment with Albendazole required 0.06 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0) mean day\u0026rsquo;s wage at the CHC and HP, and 0.08 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06) at the PHC. Treatment of childhood anaemia with Fersolate and Albendazole were almost the same in all the facility but marginally higher at the PHC.\u003c/p\u003e\n\u003cp\u003eThe mean day\u0026rsquo;s wage for treatment of typhoid in children was 0.18 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02) at the CHC, and 0.19 at the HP using Chloramphenicol and Co-trimoxazole. Treatment of typhoid in children was more affordable in CHC (required 0.18 day\u0026rsquo;s wage) and less at the PHC (required 0.20 day\u0026rsquo;s wage). Treatment with Co-trimoxazole was more affordable at the PHC (required 0.17 day\u0026rsquo;s wage) and less at the HP (required 0.19 day\u0026rsquo;s wage.)\u003c/p\u003e\n\u003cp\u003eOne out of the three CHC had a good DRF performance, one had a fair DRF performance and one had a poor DRF performance. Out of the seventeen PHC studied, two had a good DRF performance, three had a fair DRF performance and twelve had a poor DRF performance. The two HP had a poor DRF performance. The performance of DRF was not dependent on the type of health facility (p-value\u0026thinsp;=\u0026thinsp;0.585).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\n \u003cp\u003eThis study looked the access to essential medicines in the primary health care facilities in Esan South East; to provide relevant information for planning effective primary health care for the community. Specifically, the study sought to determine the affordability of essential medicines and Drug Revolving Fund Performance, to influence essential drug programme managers and redirect health policy makers to factors that affect pharmaceutical care provisions.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eAffordability of Essential Medicines\u003c/h3\u003e\n\u003cp\u003eProvision of promotive, preventive, curative and rehabilitative health services require regular availability of relevant medicines of proven safety, efficacy and quality at an affordable price.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003eHigh cost of medicines is a major barrier to accessing medicines and achieving better health outcomes.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Affordability in this study was calculated in terms of the number of days the lowest paid unskilled government worker would have to work to pay for one treatment course for an acute condition or one month\u0026rsquo;s treatment for a chronic condition. At the time of the study, the lowest paid unskilled government worker in Esan southeast earned seven hundred and seventy naira ( 770) per day (equivalent to 3.88USD per day) as of July 2015. On the average the lowest paid worker would require 0.34(representing 34%) of a day\u0026rsquo;s wage for the treatment of malaria in adults using artemisinin combination therapy, while with quinine it required 0.5 (representing 50%) of a day\u0026rsquo;s wage. Also for the treatment of childhood diseases, malaria treatment required 0.07 days wage (representing 7% of a day\u0026rsquo;s wage) using ACT while treatment with quinine required 0.43 day\u0026rsquo;s wage (representing 43% of a day\u0026rsquo;s wage).The cost of treatment differed with different treatment options for a particular disease condition in both adults and children per facility. It was cheaper to manage malaria using ACT than quinine in both adults and children. However the costs of treatment of disease conditions with respect to treatment options were almost the same in the different types of facility (i.e. CHC, PHC and HP).The mean day\u0026rsquo;s wage for treatment of adults diseases across facility was 0.21 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08) representing 21% of a day\u0026rsquo;s wage. The mean day\u0026rsquo;s wage for the treatment of childhood diseases was 0.23 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07) representing 23% of a day\u0026rsquo;s wage. In a study conducted in Ghana an average of 1.67 day\u0026rsquo;s wage (representing167% of a day\u0026rsquo;s wage) was needed to treat adult\u0026rsquo;s disease condition and 0.78 day\u0026rsquo;s wages (representing 78% of a day\u0026rsquo;s wage) for a child\u0026rsquo;s disease condition. In the same survey a complete course of treatment of malaria required 1.3 day\u0026rsquo;s wage (representing130% of a day\u0026rsquo;s wage). A similar study carried out in Sudan showed an average of 0.62 day\u0026rsquo;s wage (representing 62% of a day\u0026rsquo;s wage) for treatment of malaria.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003eEven though the cost of treatment varies marginally according to type of facility in the management of some ailments, affordability was not crucial as no treatment option required more than a day\u0026rsquo;s wage for treatment. This may have been due to subsidy applied to the medicines supplied to the primary health facilities in the LGA. This may impact positively on patients\u0026rsquo; health care seeking behaviour to the primary health care facilities in the LGA.\u003c/p\u003e\n\u003ch3\u003ePerformance of Drug Revolving Fund (DRF)\u003c/h3\u003e\n\u003cp\u003eOne of the major indices of the performance of the primary healthcare delivery remains improved access to essential drugs. The more commonly used mechanisms to address inequities in rural access to medicines was the establishment of drug revolving funds, whereby a capital investment allows for the initial purchase of medicines and revenues from medicine sales or user fees are used to replenish stock. Sustainable and successful schemes have been described across Africa. \u003csup\u003e25, 26,27\u003c/sup\u003eAccording to this study one out of the three CHC (representing 33.3% of the total CHC) had a good performance of DRF, and then two out of seventeen PHC (representing11.8%) had a good performance of DRF. None of the HP had a working DRF. Majority of the health facilities (68.2%) had a poor performance of DRF [shown in Table \u003cspan class=\"InternalRef\"\u003e18\u003c/span\u003e]. This was due to non-operational DRF in most of the health care facilities.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n \u003cp\u003eEssential medicines for treatment of common diseases and for reproductive health in 2015 in primary health facilities in Esan Southeast L.G.A were largely affordable. On the average no treatment option required more than 50% of a day\u0026rsquo;s wage for treatment. The performance of DRF varied according to facility type, affordability was not crucial as no treatment option required more than a day\u0026rsquo;s wage for treatment. This may have been due to subsidy applied to the medicines supplied to the primary health facilities in the LGA had a positive influence on the affordability of essential medicines for treatment of common diseases and for reproductive health. A working Drug Revolving Fund Scheme is critical to health commodity security in primary health care facilities.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\n \u003ch2\u003eRecommendations\u003c/h2\u003e\n \u003cp\u003eThe study recommends that:\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. Revision of different financing options such as Drug Revolving Fund and community health insurance scheme need to be implemented.\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e2.\u0026nbsp;\u003c/span\u003e\u003cspan\u003eThere is need for Local Government Health Authority to ensure availability of a robust and functional DRF in all health facilities in the LGA.\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate:\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Irua specialist Teaching Hospital (ISTH) ethical review committee\u003c/p\u003e\n\u003cp\u003eConsent for Publication:\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials:\u003c/p\u003e\n\u003cp\u003eThe data supporting this study\u0026apos;s findings is provided as an attachment to the submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests:\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; Contributions\u003c/p\u003e\n\u003cp\u003eIfijeh Frederick conceived the study, led the manuscript writing, and coordinated data interpretation. Bravo Otohabru contributed to the contextual interpretation of health facility operations and policy alignment. Ejiyere Harrison. O conducted the statistical analysis and contributed to the interpretation of the data. All authors read, reviewed and approved of the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eIfijeh Frederick appreciates the support of the Edo State Ministry of Health, Primary Health care Development Agency, Local Government civil Service commission and medical officer of Health for granting approvals for this research.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; Information:\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2023) Universal access to essential medicines: 2023 global status report. 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IBM corp, NY\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGilson L, Kitange H, Teuscher T (1993) Assessment of process quality in Tanzanian primary care. Health Policy 26:119\u0026ndash;139\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan der Geest S (2000) User fees and drugs: what did the health reforms in Zambia achieve? Health Policy Plann 15(1):59\u0026ndash;65\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEverard M (2002) Access to medicines in low-income countries. Int J risk Saf Med 15:137\u0026ndash;149\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheraghali AM, Nikfar S, Behmanesh Y, Rahimi V, Habibipour F, Tirdad R (2004) Evaluation of availability, accessibility and prescribing pattern of medicines in the Islamic Republic of Iran. East Mediterr Health J 10(3):406\u0026ndash;415\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUzochukwu BSC, Onwujekwe O, E and, Akpala C (2002) Effect of the Bamako-Initiative drug revolving funds availability and rational use of essential drugs in primary health care facilities in south-east Nigeria. Health Policy Plann 17:4: 378\u0026ndash;383\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWaning B, Maddix, Tripodis Y, Laing R, Leufkens HG, Gokhale M (2009) Towards equitable access to medicines for the rural poor: initiative triggers price competition in Kyrgyzstan. Int J Equity Health 8:43\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli GKM (2009) Accessibility of medicines and primary health care: The impact of the revolving drug fund in Khartoum State. Afr J Pharm Pharmacol 3:70\u0026ndash;77\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 3 to 18 are available in the Supplementary Files section.\u003c/p\u003e"},{"header":"Appendix","content":"\u003cp\u003eAppendix iii is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Management Sciences for Health","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Essential medicines, Affordability, Primary Health Care facilities, Drug Revolving Fund, Esan Southeast, Edo State","lastPublishedDoi":"10.21203/rs.3.rs-7629722/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7629722/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEssential medicines save lives and improve health, when they are available, affordable, of assured quality and used rationally. High cost of medicines is a major barrier to accessing medicines and achieving better health outcomes. This study assessed the effect of Drug Revolving Fund performance on affordability of essential medicines in the primary health care facilities in Esan Southeast local government in southern Nigeria.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eThe study was a descriptive cross-sectional study that employed both quantitative and qualitative approaches, following the standardized World Health Organization and Health Action International (WHO/HAI) methodology. Prices of 27 key essential medicines (EDs) for treatment of common diseases and 12 key essential medicines used in reproductive health were assessed in 22 primary health care facilities in Esan Southeast. The operation of Drug Revolving Fund was also explored with the use of researcher administered questionnaire to determine its performance and effect on affordability of EDs. The daily wage of the lowest paid unskilled government worker was used to gauge the affordability of essential medicines.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe results showed that on the average the lowest paid worker would require 0.34 (representing 34%) of a day\u0026rsquo;s wage for the treatment of malaria in adults using artemisinin combination therapy (ACT), while with quinine it required 0.5 (representing 50%) of a day\u0026rsquo;s wage. Also for the treatment of childhood diseases, malaria treatment required 0.07 days wage (representing 7% of a day\u0026rsquo;s wage) using ACT while treatment with quinine required 0.43 day\u0026rsquo;s wage (representing 43% of a day\u0026rsquo;s wage). According to this study one comprehensive health centre (representing 33.3% of the total CHC) out of the three CHC had a good performance of DRF, and then two out of seventeen PHC (representing 11.8% of the total PHCs) had a good performance of DRF. None of the HP had a working DRF. Majority of the health facility had a poor performance of DRF. Health facilities with good performance of DRF also had good affordability of EDs for treatment of common diseases and vice versa. The same was true for EDs used in reproductive health.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEssential medicines for treatment of adults and child\u0026rsquo;s disease conditions were largely affordable. Alternative health financing options together with the performance of DRF had effects on affordability of essential medicines for treatment of common diseases and for reproductive health. A working Drug Revolving Fund Scheme is critical to affordable access to essential medicines in primary health care facilities.\u003c/p\u003e","manuscriptTitle":"Assessment of Essential Medicines Affordability in Primary Health Care Facilities in Southern Nigeria: “Effect of Drug Revolving Fund Performance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:49:39","doi":"10.21203/rs.3.rs-7629722/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"316b6cbb-0897-458f-bbeb-bc7ae34d62c7","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54806244,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2025-09-23T07:49:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 07:49:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7629722","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7629722","identity":"rs-7629722","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}