A systematic scoping review of medicine availability and affordability in Africa

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Access to safe, effective, quality and affordable essential medicines has become a key agenda at national and international levels following the adoption of the Sustainable Development Goals (SDG). This agenda is especially important in African countries where numerous studies have found high levels of medicine unavailability and unaffordability. In 2003, the World Health Organization (WHO)/ Health Action International (HAI) published a manual for assessing medicine availability and affordability. To date, there has not been a systematic study appraising medicine affordability and availability studies in the Africa region that identifies the methodologies and measures used to measure and monitor progress. Methods . We conducted a systematic scoping review of studies assessing medicine availability or affordability conducted in the WHO Africa region in the years 2009-2021. Results. 244 articles met our eligibility criteria. A majority (87%) of the articles reported descriptive studies, while 11% reported interventional studies. More than two-thirds (68%) reported studies conducted in four countries in eastern Africa. The most commonly studied medicines were antiparasitic and anti-bacterial medicines. The most commonly used measures of medicine availability were whether a medicine was in stock on the date of a survey, whether stockouts occurred during a particular period, whether a medicine was on a stock list, amount of stock available, respondent self-reported availability and prescription refill data. Of the 59 articles that included affordability measures, 39 compared the price of the medicine to the daily wage of the lowest paid government worker. Other affordability measures were patient self-reported affordability, capacity to pay based on individual income and expenses, and comparing medicines prices with a population-level income standard (such as minimum wage, poverty line, or per capita income). Conclusion. Our results indicate substantial adoption of the medicine availability and affordability assessment methodology recommended by WHO/HAI, but also revealed a promising set of alternative methods and measures. Our review also indicated a need for greater focus on medicines for certain non-communicable diseases, including anti-neoplastics, greater geographic diversity in the countries where these studies are conducted, and more interventional studies to identify interventions for improving access to medicines in the region. Medicines Pharmaceuticals Availability Affordability Africa Figures Figure 1 Background Lack of access to medicines due to poor availability or affordability negatively affects health service quality and equity in Africa in a variety of ways. Medicine affordability or availability in Africa has been associated with medication adherence, 1 , 2 , 3 prescribing decisions, 4 , 5 , 6 patient choice of health facility, 7 , 8 , 9 patient satisfaction, 10 , 11 , 12 care seeking behavior, 13 , 14 referral patterns, 15 compliance with treatment guidelines, 16 and health outcomes. 17 , 18 , 19 Unaffordability of medicines in the formal sector has also been shown to drive patients to informal markets where medicine quality may be poor. 20 In 2011, the World Health Organization (WHO) published the World Medicines Situation Report that included results of nine years of surveys from multiple WHO regions measuring affordability and availability of a basket of essential medicines using the WHO/Health Action International (HAI) cross-sectional facility survey methodology that was originally published in 2003. 21 An analysis of similar survey results was published by Cameron et al. in 2009. 22 Prior versions of the World Medicines Situation Report were published in 2004 23 and 1988. 24 The 2011 report included the results of medicine availability and affordability surveys from 11 African countries. The surveys from the Africa region reported substantial challenges and variability in the availability and affordability of essential medicines in the public and private sectors. A World Medicines Situation Report has not been published since 2011. In 2015 the United Nations General Assembly adopted the Sustainable Development Goals (SDGs), which included ensuring “access to safe, effective, quality and affordable essential medicines and vaccines for all” as part of Target 3.8. Following the SDGs declaration, access to medicines has become central to discussions around achievement of Target 3.8. There is a need to better understand the state of medicine availability and accessibility in the Africa region since the 2011 Medicines Situation Report and progress made toward Target 3.8. Since the publication of the 2011 Medicines Situation Report, medicine availability and affordability studies using varying methodologies continued to be conducted in the WHO Africa region. 25 , 26 , 27 , 28 , 29 To date, there has not been a systematic effort to collect and analyze these studies, how their approaches might differ, and gaps in the literature. A greater understanding of the methodologies used by these studies, their location, medicines of interest, and findings could provide important context for monitoring progress against SDG Target 3.8. To address this gap, we conducted a systematic scoping of the literature for medicine availability and affordability surveys and related studies conducted in the WHO Africa region from 2009 through 2021. Methods A systematic scoping review is used to identify the types of available evidence in a given field; clarify key concepts and definitions in the literature; examine how research is conducted on a certain topic or field; identify key characteristics or factors related to a concept; and identify and analyze knowledge gaps. 30 We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. 31 The protocol was registered on Open Science Framework on August 11, 2021 (osf.io/t2gdq). 32 Our inclusion criteria were: (1) analysis of medication availability or affordability; (2) qualitative or quantitative analysis; (3) geographic focus on countries in WHO Africa Region; (4) English language; (5) published after 2008. Our exclusion criteria were: (1) not available in below referenced databases; (2) not available in English (due to language limitations of study team); (3) assessments of availability/affordability of other types of health supplies/equipment/diagnostics only; (4) last year of data collection was 2005 or earlier (this last exclusion criteria was added during the screening process to exclude older studies with data collected outside of our time period of interest). We conducted searches on August 2, 2021, in the following databases: (1) Medline (PubMed), (2) EMBASE, and (3) WHO Global Index Medicus. The search terms for Medline (PubMed), EMBASE, and WHO Global Index Medicus are listed in Table 1 . We reviewed all studies in the HAI Medicine Prices, Availability, Affordability & Price Components Database 33 against our criteria after completing the literature screening and included reports from the HAI database that were not included in the literature results. We de-duplicated the responsive articles using EndNote and Rayyan. Table 1 Search Terms Database PubMed (Medline) Search Terms ((Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cabo Verde OR Cameroon OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR "Democratic Republic of Congo" OR "Equatorial Guinea" OR Eritrea OR Eswatini OR Ethiopia OR Gabon OR Gambia OR Ghana OR "Guinea Bissau" OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mozambique OR Namibia OR Niger OR Nigeria OR Rwanda OR "Sao Tome and Principe" OR Senegal OR Seychelles OR "Sierra Leone" OR "South Africa" OR "South Sudan" OR Togo OR Uganda OR Tanzania OR Zambia OR Zimbabwe) AND ("medicine*"[tiab] OR "pharmaceutical*" OR "Pharmaceutical Preparations"[Mesh]) AND ("affordability" or "availability")) AND (("2009"[Date - Publication] : "3000"[Date - Publication])) Date Search Conducted 2 Aug 2021 Number of Results 1126 Database Embase Search Terms (('algeria' OR 'algeria'/exp OR algeria OR 'angola' OR 'angola'/exp OR angola OR 'benin' OR 'benin'/exp OR benin OR 'botswana' OR 'botswana'/exp OR botswana OR 'burkina faso'/exp OR 'burkina faso' OR 'burundi' OR 'burundi'/exp OR burundi OR cabo) AND verde OR 'cameroon' OR 'cameroon'/exp OR cameroon OR 'central african republic'/exp OR 'central african republic' OR 'chad' OR 'chad'/exp OR chad OR 'comoros' OR 'comoros'/exp OR comoros OR 'congo' OR 'congo'/exp OR congo OR 'cote divoire' OR 'democratic republic of congo' OR 'equatorial guinea'/exp OR 'equatorial guinea' OR 'eritrea' OR 'eritrea'/exp OR eritrea OR 'eswatini' OR 'eswatini'/exp OR eswatini OR 'ethiopia' OR 'ethiopia'/exp OR ethiopia OR 'gabon' OR 'gabon'/exp OR gabon OR 'gambia' OR 'gambia'/exp OR gambia OR 'ghana' OR 'ghana'/exp OR ghana OR 'guinea bissau'/exp OR 'guinea bissau' OR 'kenya' OR 'kenya'/exp OR kenya OR 'lesotho' OR 'lesotho'/exp OR lesotho OR 'liberia' OR 'liberia'/exp OR liberia OR 'madagascar' OR 'madagascar'/exp OR madagascar OR 'malawi' OR 'malawi'/exp OR malawi OR 'mali' OR 'mali'/exp OR mali OR 'mauritania' OR 'mauritania'/exp OR mauritania OR 'mauritius' OR 'mauritius'/exp OR mauritius OR 'mozambique' OR 'mozambique'/exp OR mozambique OR 'namibia' OR 'namibia'/exp OR namibia OR 'niger' OR 'niger'/exp OR niger OR 'nigeria' OR 'nigeria'/exp OR nigeria OR 'rwanda' OR 'rwanda'/exp OR rwanda OR 'sao tome and principe'/exp OR 'sao tome and principe' OR 'senegal' OR 'senegal'/exp OR senegal OR 'seychelles' OR 'seychelles'/exp OR seychelles OR 'sierra leone'/exp OR 'sierra leone' OR 'south africa'/exp OR 'south africa' OR 'south sudan'/exp OR 'south sudan' OR 'togo' OR 'togo'/exp OR togo OR 'uganda' OR 'uganda'/exp OR uganda OR 'tanzania' OR 'tanzania'/exp OR tanzania OR 'zambia' OR 'zambia'/exp OR zambia OR 'zimbabwe' OR 'zimbabwe'/exp OR zimbabwe) AND ('medicine*':ti,ab,kw OR 'pharmaceutical*':ti,ab,kw OR 'prescription drug'/exp) AND ('affordability'/exp OR 'affordability' OR 'availability'/exp OR 'availability') AND [2009–2021]/py AND [english]/lim Date Search Conducted 2 Aug 2021 Number of Results 1,220 Database WHO Global Index Medicus Search Terms ((mh:(vs2.002.001*)) OR medicine* OR pharmaceutical*) AND ("affordability" OR "availability") AND ((mh:( Z01.058*)) OR (collection_gim:("AIM"))) Date Search Conducted 2 Aug 2021 Number of Results 135 Three authors (JL, HN, and AK) independently screened each identified record by title and abstract based on the above inclusion and exclusion criteria using Rayyan. 34 JL independently reviewed all records and HN and AK each reviewed 50% of the responsive abstracts. Any disagreements were resolved via discussion by the review authors. Three authors (JL, HN, and AK) then independently reviewed the full text of screened in articles based on the above inclusion and exclusion criteria and entered review decision in Rayyan. JL reviewed all screened full text articles and AK and HS each reviewed 50% of the screened full text articles. Any disagreements on responsiveness were resolved via discussion by the three review authors. Data extraction was then conducted by JL. The following data elements were extracted into Excel and descriptive statistics were used to analyze the extracted data: Study ID; authors; article title; publication year; data collection year(s); journal title; country(ies) where study conducted; type of study (free text); type of study (select from descriptive, correlation, or intervention); types of medicines studied; types of facilities/locations studied; types of respondents (if applicable); availability measure(s); and affordability measure(s). The dataset is available as a supplemental file. Types of medicines were categorized according to the categories of medicines used in the 2021 WHO Model List of Essential Medicines (WHO Model EML). The highest level category was used for all categories, except anti-infective medicines, for which we also used the sub-categories due to the large number of medicines in the sub-categories (i.e., anthelminthics, antibacterials, antifungal medicines, antiviral medicines, antiprotozoal medicines, and medicines for ectoparasitic infections). The categories are listed in Table 2 . Some medicines are coded to multiple categories. The categorization decisions were based on a review of three resources. First, we reviewed the 2021 WHO Model EML and medicines listed on the 2021 WHO Model EML were coded based on the category assigned in that list. If a medicine was not listed on the 2021 WHO Model EML, we reviewed the online WHO EML website to see if the medicine had been listed on a prior WHO EML. If so, we categorized the medicine based on category(ies) assigned in the previous WHO Model EML. If the medicine had not been listed on any previous WHO Model EML, we reviewed the MedLine Plus National Library of Medicine to inform the categorization decision. The coding decisions for medicines not listed on the 2021 WHO Model EML are listed in the supplemental file under coding notes. Table 2 Coding Scheme for Type(s) of Medicines Studied No. from 2021 WHO Model EML Category Name 1 Anaesthetics, Preoperative Medicines and Medical Gases 2 Medicines for Pain and Palliative Care 3 Antiallergics and Medicines Used in Anaphylaxis 4 Antidotes and Other Substances Used in Poisonings 5 Anticonvulsants/Antiepileptics 6 Anti-Infective Medicines 6.1 Anthelminthics 6.2 Antibacterials 6.3 Antifungal medicines 6.4 Antiviral medicines 6.5 Antiprotozoal medicines 6.6 Medicines for ectoparasitic infections 7 Antimigraine Medicines 8 Immunomodulators and Antineoplastics 9 Antiparkinsonism Medicines 10 Medicines Affecting the Blood 11 Blood Products of Human Origin and Plasma Substitutes 12 Cardiovascular Medicines 13 Dermatological Medicines (topical) 14 Diagnostic Agents 15 Antiseptics and Disinfectants 16 Diuretics 17 Gastrointestinal Medicines 18 Medicines for Endocrine Disorders 19 Immunologicals 20 Muscle Relaxants (peripherally-acting) and Cholinesterase Inhibitors 21 Ophthalmological Preparations 22 Medicines for Reproductive Health and Perinatal Care 23 Peritoneal Dialysis Solution 24 Medicines for Mental and Behavioural Disorders 25 Medicines Acting on the Respiratory Tract 26 Solutions Correcting Water, Electrolyte and Acid-Base Disturbances 27 Vitamins and Minerals 28 Ear, Nose and Throat Medicines 29 Medicines for Diseases of Joints 30 Dental Preparations N/A* Not specific to a particular medicine * We coded some studies as “Not specific to a particular medicine” which was not a category in the WHO Model EML Results Our searches of Medline/PubMed, EMBASE, and Global Index Medicus identified 2,481 total results (1,126 from Medline/PubMed, 1,220 from EMBASE, and 135 from Global Index Medicus). We used EndNote and Rayyan to de-duplicate the search results, resulting in 1,808 articles for abstract screening. Based on our review of article abstracts, we identified 405 abstracts as potentially meeting our criteria and were able to retrieve 310 articles for full text screening. Following full text screening, we identified 250 articles as meeting our criteria. We identified three (3) additional articles in the HAI Medicine Prices, Availability, Affordability & Price Components Database that met our criteria, the results of which were not published in articles already captured by our literature searches. This increased the total number of articles included to 253. During the data extraction process we further excluded 9 articles based on a secondary review, leaving a total of 244 articles in our final dataset. The full list of articles, including title, authors, journal title, and year published, is listed in the supplemental file. The record inclusion and exclusion decisions are described in the PRISMA flow diagram included as Fig. 1 . Types of Studies . Most articles (212/244; 87%) were descriptive studies. Only 11% (n = 28) of all the articles were intervention studies that examined the potential effect of programmatic or other interventions on medicine availability and/or affordability. The remaining four (4) articles were reviews. Of the descriptive studies, 27% (57/212) used statistical analytical techniques to identify associations between medicine availability and/or affordability measures and other variables, such as medication adherence, 35 use of medicines, 36 or compliance with treatment guidelines. 37 Study Locations . Table 3 shows the study location(s) by country. Our results included studies from 26 out of 47 (55%) countries in the WHO Africa Region. The countries with the greatest number of studies were Tanzania (50), Uganda (49), Ethiopia (35), Kenya (33), Nigeria (29), and Ghana (21). Some articles included study sites in multiple countries. The list of study sites for each article is listed in the supplemental file. Table 3 Study Location(s) by Country Country No. of Articles Country (continued) No. of Articles Tanzania 50 Benin 5 Uganda 49 Senegal 5 Ethiopia 35 Burkina Faso 4 Kenya 33 Sierra Leonne 4 Nigeria 29 Madagascar 3 Ghana 21 Mali 3 South Africa 15 Zimbabwe 3 Zambia 12 Botswana 2 Malawi 10 Gambia 2 Cameroon 7 Swaziland 2 Democratic Republic of Congo 7 Burundi 1 Rwanda 7 Congo 1 Mozambique 6 Lesotho 1 Types of Medicines Studied . Table 4 shows the number of articles that analyzed medicine availability and/or affordability for different categories of medicines, based on the categorization scheme used in the 2021 WHO Model EML. The categories of medicines most commonly studied were antiprotozoal medicines (100 articles) (primarily antimalarials) and antibacterials (93 articles), followed by cardiovascular medicines (70 articles), gastrointestinal medicines (66 articles), medicines for reproductive health and perinatal care (65 articles), medicines for pain and palliative care (62 articles), and medicines for endocrine disorders (62 articles). We did not identify any articles on medicines for ectoparasitic infections, peritoneal dialysis solution, or dental preparations. Table 4 Types of Medicines Studied Medicine Category No. of Articles Medicine Category (continued) No. of Articles Antiprotozoal medicines 100 Diuretics 23 Antibacterials 93 Anaesthetics, Preoperative Medicines and Medical Gases 21 Cardiovascular Medicines 70 Dermatological Medicines (topical) 21 Gastrointestinal Medicines 66 Anthelminthics 20 Medicines for Reproductive Health and Perinatal Care 65 Vitamins and Minerals 20 Medicines for Pain and Palliative Care 62 Immunologicals 17 Medicines for Endocrine Disorders 62 Antifungal medicines 15 Medicines Acting on the Respiratory Tract 46 Medicines for Diseases of Joints 14 Antimigraine Medicines 45 Ear, Nose and Throat Medicines 7 Anticonvulsants/Antiepileptics 43 Antiseptics and Disinfectants 6 Ophthalmological Preparations 37 Antidotes and other Substances used in Poisonings 5 Medicines for Mental and Behavioural Disorders 37 Blood Products of Human Origin and Plasma Substitutes 4 Not specific to a particular medicine 35 Antiparkinsonism Medicines 3 Antiviral medicines 28 Diagnostic Agents 1 Antiallergics and Medicines used in Anaphylaxis 27 Muscle Relaxants (peripherally-acting) and Cholinesterase Inhibitors 1 Immunomodulators and Antineoplastics 26 Medicines for ectoparasitic infections 0 Solutions Correcting Water, Electrolyte and Acid-base Disturbances 25 Peritoneal Dialysis Solution 0 Medicines Affecting the Blood 24 Dental Preparations 0 Availability Measures . We identified 197 articles that included studies that measured medicine availability and categorized the availability measures used into six categories. The most common measure was whether a medicine was in stock on the date of a survey (i.e., cross-sectional survey) (124 articles). This included, but was not limited to, studies that used the WHO/HAI survey methodology. The second most common measure was whether stockouts occurred during a particular time period (48 articles). Often these two measures were combined. For example, Iwu, Ncobo, et al. combined the first two measures to assess the occurrence of stockouts of six tracer vaccines in Eastern Cape, South Africa. 38 They assessed whether the vaccine was available on the date of a survey and in the preceding 24 months using a questionnaire, record checks, and observation. The third most common medicine availability measure was respondent self-reported availability of a particular medicine (18 articles). Aweucha, Janefrances, et al. used this approach to examine the impacts of the COVID-19 pandemic on patient access to essential medicines. 39 They implemented a cross-sectional survey using electronic questionnaires across 36 states of Nigeria by asking patients whether they had “Difficulty accessing essential medicines” before and/or during the COVID-19 pandemic. Six articles used a measure of whether a medicine was on a stock list only. Five articles used a measure of the amount of stock available for a particular medicine. Kusemererwa, Alban, et al. used a stock level measure to assess medicine availability in the Uganda’s public sector. 40 They measured facility stock levels and characterized stock as optimally stocked, understocked, or overstocked. An item was considered optimally stocked if the facility had two to five months of stock, understocked if it had less than two months, and overstocked if it had more than five months. To calculate the months of stock on hand, the authors divided the stock level on the day of the study by its average monthly consumption. We also identified three articles that used prescription refill data to inform their assessment of medicine availability. Table 5 summarizes the primary availability methods and measures used by the studies in our review. Table 5 Medicine Availability Methods & Measures Availability Methods Availability Measures Facility stock surveys (e.g., identified surveyor or mystery shopper) Whether medicine was in stock on a certain date Stock level on a certain date (e.g., stockout, low stock, medium stock, high stock) Retrospective review of facility or system-level medicine stock data/records (e.g., paper bin cards, routine data systems) Whether medicine was included on the facility stock list Whether stockout occurred during date range (e.g., 1, 6, or 12 months) Daily stock levels during date range (e.g., stockout, low stock, medium stock, high stock) Prescription refill rate during date range Patient or health worker self-reported availability (Ask) how often certain medicines are available/unavailable based on their experience (e.g., never, rarely, sometimes, most often, always) (Ask) whether they agree with a statement that describes the goal of consistent availability of medicines or the problem of unavailability of medicines (e.g., my facility has enough [insert name of medicine]; (2) I am limited by the unavailability of [insert name of medicine]) Affordability Measures . We identified 59 articles with studies that included measures of medicine affordability, of which the most common affordability measure compared the price of the medicine to the daily wage of the lowest paid government worker (32 articles). This is the measure used in the WHO/HAI methodology. The second most common affordability measure was patient self-reported affordability (9 articles). The methodology employed by Embrey, Vialle-Valentin, et al. included a household survey in Tanzania that asked respondents whether they “had to sell things or borrow money to pay for medicines at some time in the past” and whether the household could “usually afford to buy needed medicines.” 41 Oridanigo, Salgedo, and Kebene used both a self-reported/perceived affordability measure and a standardized measure (i.e., daily wages of the lowest paid government worker) to measure medicine affordability in Ethiopia. 42 Oyando, Njoroge, et al. conducted a patient survey in Kenya to assess affordability of hypertension care and asked patients if they did any of the following to cover hypertension care costs: “borrowing (having taken a loan), selling household items or assets (eg, livestock), and use of savings.” 43 Five articles reported studies that used capacity to pay or similar calculation based on individual income and expenses. Khatib, McKee, et al. 44 and Attaei, Khatib, et al. 45 characterized medicines as affordable if the combined cost was less than 20% of household capacity-to-pay. Capacity-to-pay was calculated based on the household income remaining after basic subsistence needs have been met. A smaller number of studies measured affordability by comparing medicines prices with a population-level income standard such as per capita income (4 articles), minimum wage (4 articles), or the national poverty line (1 article). For example, Khuluza and Haefele-Abah used the statutory minimum daily wage of Malawi as the affordability threshold. 46 Table 6 summarizes the primary affordability methods and measures used by the studies in our review. Table 6 Medicine Affordability Methods & Measures Affordability Methods Affordability Measures Compare medicine prices with population-level affordability standard Daily wage of lowest paid government worker National poverty line Daily minimum wage Daily per capita income Calculate percentage of actual household income spent on medicines Percent of actual household income spent on medicines Capacity-to-pay measures (e.g., % of household income spent on medicines after covering basic subsistence needs) Self-reported affordability of medicines Ask whether the household could usually afford to buy needed medicines Ask whether they took any steps that might indicate financial hardship to buy medicines (e.g., borrowing money, taking out a loan, selling household items or assets, or using savings intended for another purpose) Discussion Our results revealed that 63% of articles with medicine availability studies (124/197) and 54% of articles with medicine affordability studies (32/59) conducted in Africa during our time period of interest used cross-sectional facility survey methodologies consistent with or similar to the WHO/HAI methodology. This shows the continued importance and impact of the WHO/HAI methodology in encouraging standardized survey designs that facilitate aggregating results from multiple surveys. This standardization allows for comparing medicine availability and affordability between countries/regions and conducting repeat surveys with the same methodology to identify changes over time. We also found a substantial number of studies using alternative approaches to measure medicine availability and/or affordability that may complement the WHO/HAI methodology. For example, 24% of the articles with availability studies used a retrospective review of stock records to capture longitudinal data on medicine availability. These longitudinal studies can measure availability over time and provide additional insight on seasonality or other factors that can affect medicine stock rates, such as whether low stock or stockouts occur more frequently at the end of a month/quarter or during certain times of year, for instance the rainy season. For affordability studies, 52% of the articles with affordability studies used the WHO/HAI methodology of comparing medicine prices with the daily wages of the lowest paid government worker. However, 15% of the articles with affordability studies used patient self-reported affordability measures and 8% used actual household-level income and expense data to assess affordability. Furthermore, 15% used a population-level threshold for affordability other than the wages of the lowest paid government worker, such as per capita income, minimum daily wage, or national poverty line. Our finding that 87% of articles presented descriptive studies and only 11% presented intervention studies illustrates both the importance of descriptive studies to this topic and the need for additional intervention studies. Additional intervention studies will be critical to identifying and scaling promising approaches to improve medicine availability and affordability. The extensive use of mixed methods approaches in our results was also noteworthy. Many of the studies in our results included a supply-side medicine availability survey and some type of qualitative methods component, such as key informant interviews, questionnaires, or surveys. The Environmental Profile of a Community's Health (EPOCH) instrument used by Attaei, Khatib, et al. is a good example of a mixed method approach that used “direct observation of the physical and commercial environment and a survey of perceptions of the environment by those living in it” to assess availability and affordability blood-pressure lowering medicines in 20 countries. 47 The most commonly studied medicines in our results were antiprotozoal medicines, including antimalarials, and antibacterials, including anti-TB medicines. Antiprotozoal medicines being the most studied category of medicines reflects the substantial burden of malaria in Africa and the important role of antimalarial medicines in reducing malaria morbidity and mortality. Antibacterials being the second most commonly studied medicine also illustrates the focus of addressing the burden of infectious diseases in Africa, including the high burden of tuberculosis in many countries in the region. However, medicines for non-communicable diseases, such as cardiovascular, reproductive health and perinatal care, gastrointestinal, and endocrine disorders, were also examined in a large number of studies, signifying the double burden of communicable and non-communicable diseases within the countries. However, our results only identified 26 articles that included medicines for immunomodulators and antineoplastics, such as anti-cancer medicines. As the burden of disease in Africa continues to shift toward non-communicable diseases, there will be an increasing need for medicine availability and affordability studies for these types of medicines. Increasing the number of countries implementing and publishing the results will also be important for regional monitoring, as our review only identified studies implemented in 26 out of 47 countries in the region. Many studies in our results collected primary data, but a substantial number of studies relied on data collected through largescale surveys, such as the Service Availability and Readiness Assessment survey, 48 or accessed routine data systems with data collected and maintained by a government agency. Integrating medicine availability and affordability questions into these population-level survey instruments may present an opportunity to monitor medicine availability and affordability at the population-level at minimal additional costs. We have also seen countries publish medicine availability and distribution data on public dashboards during the COVID-19 pandemic, and these dashboards and their underlying datasets may present opportunities for collaborative medicine availability or affordability monitoring between researchers and government agencies. For example, South Africa established a COVID-19 public dashboard that showed COVID-19 vaccine administration and coverage data 49 and the U.S. established a medicine availability dashboard for COVID-19 therapeutics that showed stock levels at more than 33,000 public and private health facilities. 50 Due to the costs associated with conducting primary data collection, incorporating medicine availability and affordability questions into existing population survey questionnaires and leveraging routine data systems of ministries and departments of health may present opportunities for efficient population-level monitoring of medicine availability and affordability. Conclusions Our review revealed a diversity of methodologies and measures being used to study the availability and affordability of medicines across Africa. The results showed the important role that the WHO/HAI methodology has played in standardizing medicine availability and affordability surveys across the region. They also showed the role other methodologies play in measuring medicine availability and affordability, including longitudinal studies using medicine stock record reviews and patient or health worker self-reported availability. While the majority of affordability studies used the wages of the lowest paid government worker to assess affordability, we also found a number of other affordability measures being used (e.g., minimum wage, per capita income, or poverty line). We also found other methodologies for measuring affordability, including calculating percentage of actual household income spent on medicines and/or self-reported affordability of medicines using population surveys or interviews. As the burden of non-communicable diseases increases in Africa, there will be an increasing need to focus medicine availability and affordability studies on medicines for non-communicable conditions and greater funding and focus may be needed for intervention studies to help identify systems and processes that may increase access to these medicines. Our hope is that this review and the methods and measures described herein will be a useful reference for researchers and governments in designing studies and routine monitoring systems to measure and ultimately improve the availability and affordability of medicines in the region. Declarations Ethics approval and consent to participate: Not applicable. This review did not involve human subjects research Consent for publication: Not applicable. This review did not involve human subjects research Availability of data and materials: The underlying data file is included with this manuscript as a supplemental file. Competing interests: None Funding: None Authors' contributions : JL (Conceptualization; Methodology; Formal Analysis; Writing – Original Draft); HN (Methodology; Formal Analysis; Writing – Review & Editing); AK (Methodology; Formal Analysis; Writing – Review & Editing); YD (Conceptualization; Methodology; Writing – Review & Editing); AS (Conceptualization; Methodology; Writing – Review & Editing); WO (Conceptualization; Methodology; Writing – Review & Editing) Acknowledgements : None References Attaei MW, Khatib R, McKee M, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411-e419. doi:10.1016/S2468-2667(17)30141-X Adisa R, Olajide OO, Fakeye TO. Social Support, Treatment Adherence and Outcome among Hypertensive and Type 2 Diabetes Patients in Ambulatory Care Settings in southwestern Nigeria. Ghana Med J. 2017;51(2):64-77. Mendenhall E, Norris SA. Diabetes care among urban women in Soweto, South Africa: a qualitative study. BMC Public Health. 2015;15:1300. Published 2015 Dec 26. doi:10.1186/s12889-015-2615-3 Oduro-Mensah E, Kwamie A, Antwi E, et al. Care decision making of frontline providers of maternal and newborn health services in the greater Accra region of Ghana. PLoS One. 2013;8(2):e55610. doi:10.1371/journal.pone.0055610 Ogunleye OO, Fadare JO, Yinka-Ogunleye AF, Anand Paramadhas BD, Godman B. Determinants of antibiotic prescribing among doctors in a Nigerian urban tertiary hospital. Hosp Pract (1995). 2019;47(1):53-58. doi:10.1080/21548331.2018.1475997 Abahamye A, Antibiotic stewardship: Factors influencing the choice and outcomes of antimicrobial therapy in a resource-limited, rural, public hospital in uMkhanyakude District, KwaZulu-Natal, South Africa: Pre-intervention phase, S Afr Pharm J 2016;83(8):35-44. Honda A, Ryan M, van Niekerk R, McIntyre D. Improving the public health sector in South Africa: eliciting public preferences using a discrete choice experiment. Health Policy Plan. 2015 Jun;30(5):600-11. doi: 10.1093/heapol/czu038. Epub 2014 May 29. PMID: 24876077. Lungu EA, Guda Obse A, Darker C, Biesma R. What influences where they seek care? Caregivers' preferences for under-five child healthcare services in urban slums of Malawi: A discrete choice experiment. PLoS One. 2018 Jan 19;13(1):e0189940. doi: 10.1371/journal.pone.0189940. PMID: 29351299; PMCID: PMC5774690. Kruk ME, Rockers PC, Tornorlah Varpilah S, Macauley R. Population preferences for health care in liberia: insights for rebuilding a health system. Health Serv Res. 2011 Dec;46(6pt2):2057-78. doi: 10.1111/j.1475-6773.2011.01266.x. Epub 2011 Apr 21. PMID: 21517835; PMCID: PMC3392998. Nigussie S, Edessa D. The Extent and Reasons for Dissatisfaction From Outpatients Provided With Pharmacy Services at Two Public Hospitals in Eastern Ethiopia. Front Pharmacol. 2018 Oct 12;9:1132. doi: 10.3389/fphar.2018.01132. PMID: 30369880; PMCID: PMC6194162. Bezuidenhout S, Ogunsanwo DA, Helberg EA. Patient satisfaction at accredited antiretroviral treatment sites in the Gert Sibande District. Afr J Prim Health Care Fam Med. 2014 Nov 27;6(1):E1-6. doi: 10.4102/phcfm.v6i1.627. PMID: 26245422; PMCID: PMC4565049. Ketero MK, Muhammed AH, Abdi AA. Quality of Integrated Management of Newborn and Childhood Illness Services at Health Centers in Jimma, Southwest Ethiopia. Patient Prefer Adherence. 2021 Apr 15;15:793-805. doi: 10.2147/PPA.S280004. PMID: 33888979; PMCID: PMC8057089. Zalisk K, Guenther T, Prosnitz D, Nsona H, Chimbalanga E, Sadruddin S. Achievements and challenges of implementation in a mature iCCM programme: Malawi case study. J Glob Health. 2019 Jun;9(1):010807. doi: 10.7189/jogh.09.010807. PMID: 31263552; PMCID: PMC6594665. Kuwawenaruwa A, Wyss K, Wiedenmayer K, Metta E, Tediosi F. The effects of medicines availability and stock-outs on household's utilization of healthcare services in Dodoma region, Tanzania. Health Policy Plan. 2020;35(3):323-333. doi:10.1093/heapol/czz173. Beyene H, Kassa DH, Tadele HD, Persson L, Defar A, Berhanu D. Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study. BMJ Open. 2021 Jun 10;11(6):e047640. doi: 10.1136/bmjopen-2020-047640. PMID: 34112644; PMCID: PMC8194336. Bintabara D, Nakamura K, Ntwenya J, Seino K, Mpondo BCT. Adherence to standards of first-visit antenatal care among providers: A stratified analysis of Tanzanian facility-based survey for improving quality of antenatal care. PLoS One. 2019 May 13;14(5):e0216520. doi: 10.1371/journal.pone.0216520. PMID: 31083696; PMCID: PMC6513091. Attaei MW, Khatib R, McKee M, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411-e419. doi:10.1016/S2468-2667(17)30141-X. Harrison MA, Marfo AFA, Opare-Addo MNA, Ankrah DNA, Acheampong F, Nelson F, Buabeng KO. Anti-hypertensive medication access and affordability and their association with blood pressure control at a teaching hospital in Ghana. Pan Afr Med J. 2021 Jul 8;39:184. doi: 10.11604/pamj.2021.39.184.27977. PMID: 34584609; PMCID: PMC8449564. Chow CK, Nguyen TN, Marschner S, Diaz R, Rahman O, Avezum A, Lear SA, Teo K, Yeates KE, Lanas F, Li W, Hu B, Lopez-Jaramillo P, Gupta R, Kumar R, Mony PK, Bahonar A, Yusoff K, Khatib R, Kazmi K, Dans AL, Zatonska K, Alhabib KF, Kruger IM, Rosengren A, Gulec S, Yusufali A, Chifamba J, Rangarajan S, McKee M, Yusuf S; PURE Study. Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries. BMJ Glob Health. 2020 Nov;5(11):e002640. doi: 10.1136/bmjgh-2020-002640. PMID: 33148540; PMCID: PMC7640501. Derme AI, Tiono A, Hirsch F, Sirima SB. Le marché parallèle des médicaments au Burkina Faso: un marché dit illicite mais socialement construit [Pharmaceutical black market in Burkina Faso: an illicit but socially adapted market]. Med Trop (Mars). 2009 Feb;69(1):103-4. French. PMID: 19499749. Cameron A, Ewen E, Auton M, Abegunde D. The World Medicines Situation 2011 - Medicines Prices, Availability and Affordability. Geneva, Switzerland; 2011. Cameron 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):240-9. World Health Organization, The World Medicines Situation (2004), WHO/EDM/PAR/2004.5. World Health Organization, The World drug situation (1988). Abrha S, Tadesse E, Atey TM, et al. Availability and affordability of priority life-saving medicines for under-five children in health facilities of Tigray region, northern Ethiopia. BMC Pregnancy Childbirth. 2018;18(1):464. Published 2018 Nov 29. doi:10.1186/s12884-018-2109-2. Ewen M, Kaplan W, Gedif T, et al. Prices and availability of locally produced and imported medicines in Ethiopia and Tanzania. J Pharm Policy Pract. 2017;10:7. Published 2017 Jan 16. doi:10.1186/s40545-016-0095-1. Mujinja PG, Mackintosh M, Justin-Temu M, Wuyts M. Local production of pharmaceuticals in Africa and access to essential medicines: 'urban bias' in access to imported medicines in Tanzania and its policy implications. Global Health. 2014;10:12. Published 2014 Mar 10. doi:10.1186/1744-8603-10-12. Onyango MA, Vian T, Hirsch I, et al. Perceptions of Kenyan adults on access to medicines for non-communicable diseases: A qualitative study. PLoS One. 2018;13(8):e0201917. Published 2018 Aug 24. doi:10.1371/journal.pone.0201917. Ansah EK, Whitty CJ, Bart-Plange C, Gyapong M. Changes in the availability and affordability of subsidised artemisinin combination therapy in the private drug retail sector in rural Ghana: before and after the introduction of the AMFm subsidy. Int Health. 2016;8(6):427-432. doi:10.1093/inthealth/ihw041. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73. Medicines availability and affordability in WHO African region: protocol for a scoping review of literature, Aug. 11, 2021, https://osf.io/t2gdq/. https://haiweb.org/what-we-do/price-availability-affordability/price-availability-data/ Mourad Ouzzani, Hossam Hammady, Zbys Fedorowicz, and Ahmed Elmagarmid. Rayyan — a web and mobile app for systematic reviews. Systematic Reviews (2016) 5:210, DOI: 10.1186/s13643-016-0384-4. Adisa R, Olajide OO, Fakeye TO. Social Support, Treatment Adherence and Outcome among Hypertensive and Type 2 Diabetes Patients in Ambulatory Care Settings in southwestern Nigeria. Ghana Med J. 2017;51(2):64-77. Chow CK, Ramasundarahettige C, Hu W, et al. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study. Lancet Diabetes Endocrinol. 2018;6(10):798-808. doi:10.1016/S2213-8587(18)30233-X. Bintabara D, Nakamura K, Ntwenya J, Seino K, Mpondo BCT. Adherence to standards of first-visit antenatal care among providers: A stratified analysis of Tanzanian facility-based survey for improving quality of antenatal care. PLoS One. 2019 May 13;14(5):e0216520. doi: 10.1371/journal.pone.0216520. PMID: 31083696; PMCID: PMC6513091. Iwu CJ, Ngcobo N, McCaul M, et al. Vaccine stock management in primary health care facilities in OR Tambo District, Eastern Cape, South Africa. Vaccine. 2020;38(25):4111-4118. doi:10.1016/j.vaccine.2020.04.019. Emmanuel Awucha N, Chinelo Janefrances O, Chima Meshach A, Chiamaka Henrietta J, Ibilolia Daniel A, Esther Chidiebere N. Impact of the COVID-19 Pandemic on Consumers' Access to Essential Medicines in Nigeria. Am J Trop Med Hyg. 2020;103(4):1630-1634. doi:10.4269/ajtmh.20-0838. Kusemererwa D, Alban A, Obua OT, Trap B. An exploratory study on equity in funding allocation for essential medicines and health supplies in Uganda's public sector. BMC Health Serv Res. 2016;16(1):453. Published 2016 Aug 30. doi:10.1186/s12913-016-1698-6. Embrey M, Vialle-Valentin C, Dillip A, et al. Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania's Health System. PLoS One. 2016;11(11):e0164332. Published 2016 Nov 8. doi:10.1371/journal.pone.0164332. Mathewos Oridanigo E, Beyene Salgedo W, Gebissa Kebene F. Affordability of Essential Medicines and Associated Factors in Public Health Facilities of Jimma Zone, Southwest Ethiopia. Adv Pharmacol Pharm Sci. 2021;2021:6640133. Published 2021 Mar 16. doi:10.1155/2021/6640133. Oyando R, Njoroge M, Nguhiu P, et al. Patient costs of hypertension care in public health care facilities in Kenya. Int J Health Plann Manage. 2019;34(2):e1166-e1178. doi:10.1002/hpm.2752. Khatib R, McKee M, Shannon H, et al. Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet. 2016;387(10013):61-69. doi:10.1016/S0140-6736(15)00469-9. Attaei MW, Khatib R, McKee M, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411-e419. doi:10.1016/S2468-2667(17)30141-X. Khuluza F, Haefele-Abah C. The availability, prices and affordability of essential medicines in Malawi: A cross-sectional study. PLoS One. 2019;14(2):e0212125. Published 2019 Feb 12. doi:10.1371/journal.pone.0212125. Attaei MW, Khatib R, McKee M, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411-e419. doi:10.1016/S2468-2667(17)30141-X. World Health Organization, Service availability and readiness assessment (SARA), https://www.who.int/data/data-collection-tools/service-availability-and-readiness-assessment-(sara). Accessed August 26, 2022. South Africa COVID-19 Public Dashboard, https://sacoronavirus.co.za/latest-vaccine-statistics/. Accessed July 8, 2022. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, COVID-19 Therapeutics Locator, https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com (last visited July 8, 2022). Additional Declarations No competing interests reported. Supplementary Files SupplementalFile11Nov2022.xlsx Cite Share Download PDF Status: Published Journal Publication published 17 Jan, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 16 Jan, 2023 Reviews received at journal 28 Dec, 2022 Reviewers agreed at journal 07 Dec, 2022 Reviewers agreed at journal 01 Dec, 2022 Reviewers invited by journal 24 Nov, 2022 Editor assigned by journal 24 Nov, 2022 Editor invited by journal 14 Nov, 2022 Submission checks completed at journal 14 Nov, 2022 First submitted to journal 17 Sep, 2022 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. 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Medicine affordability or availability in Africa has been associated with medication adherence,\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e3\u003c/sup\u003e prescribing decisions,\u003csup\u003e4\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e6\u003c/sup\u003e patient choice of health facility,\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e9\u003c/sup\u003e patient satisfaction,\u003csup\u003e10\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e11\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e12\u003c/sup\u003e care seeking behavior,\u003csup\u003e13\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e14\u003c/sup\u003e referral patterns,\u003csup\u003e15\u003c/sup\u003e compliance with treatment guidelines,\u003csup\u003e16\u003c/sup\u003e and health outcomes.\u003csup\u003e17\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e18\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e19\u003c/sup\u003e Unaffordability of medicines in the formal sector has also been shown to drive patients to informal markets where medicine quality may be poor.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn 2011, the World Health Organization (WHO) published the World Medicines Situation Report that included results of nine years of surveys from multiple WHO regions measuring affordability and availability of a basket of essential medicines using the WHO/Health Action International (HAI) cross-sectional facility survey methodology that was originally published in 2003.\u003csup\u003e21\u003c/sup\u003e An analysis of similar survey results was published by Cameron et al. in 2009.\u003csup\u003e22\u003c/sup\u003e Prior versions of the World Medicines Situation Report were published in 2004\u003csup\u003e23\u003c/sup\u003e and 1988.\u003csup\u003e24\u003c/sup\u003e The 2011 report included the results of medicine availability and affordability surveys from 11 African countries. The surveys from the Africa region reported substantial challenges and variability in the availability and affordability of essential medicines in the public and private sectors. A World Medicines Situation Report has not been published since 2011.\u003c/p\u003e\n\u003cp\u003eIn 2015 the United Nations General Assembly adopted the Sustainable Development Goals (SDGs), which included ensuring \u0026ldquo;access to safe, effective, quality and affordable essential medicines and vaccines for all\u0026rdquo; as part of Target 3.8. Following the SDGs declaration, access to medicines has become central to discussions around achievement of Target 3.8. There is a need to better understand the state of medicine availability and accessibility in the Africa region since the 2011 Medicines Situation Report and progress made toward Target 3.8.\u003c/p\u003e\n\u003cp\u003eSince the publication of the 2011 Medicines Situation Report, medicine availability and affordability studies using varying methodologies continued to be conducted in the WHO Africa region.\u003csup\u003e25\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e26\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e27\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e28\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e29\u003c/sup\u003e To date, there has not been a systematic effort to collect and analyze these studies, how their approaches might differ, and gaps in the literature. A greater understanding of the methodologies used by these studies, their location, medicines of interest, and findings could provide important context for monitoring progress against SDG Target 3.8. To address this gap, we conducted a systematic scoping of the literature for medicine availability and affordability surveys and related studies conducted in the WHO Africa region from 2009 through 2021.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA systematic scoping review is used to identify the types of available evidence in a given field; clarify key concepts and definitions in the literature; examine how research is conducted on a certain topic or field; identify key characteristics or factors related to a concept; and identify and analyze knowledge gaps.\u003csup\u003e30\u003c/sup\u003e We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines.\u003csup\u003e31\u003c/sup\u003e The protocol was registered on Open Science Framework on August 11, 2021 (osf.io/t2gdq).\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur inclusion criteria were: (1) analysis of medication availability or affordability; (2) qualitative or quantitative analysis; (3) geographic focus on countries in WHO Africa Region; (4) English language; (5) published after 2008. Our exclusion criteria were: (1) not available in below referenced databases; (2) not available in English (due to language limitations of study team); (3) assessments of availability/affordability of other types of health supplies/equipment/diagnostics only; (4) last year of data collection was 2005 or earlier (this last exclusion criteria was added during the screening process to exclude older studies with data collected outside of our time period of interest).\u003c/p\u003e\n\u003cp\u003eWe conducted searches on August 2, 2021, in the following databases: (1) Medline (PubMed), (2) EMBASE, and (3) WHO Global Index Medicus. The search terms for Medline (PubMed), EMBASE, and WHO Global Index Medicus are listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. We reviewed all studies in the HAI Medicine Prices, Availability, Affordability \u0026amp; Price Components Database\u003csup\u003e33\u003c/sup\u003e against our criteria after completing the literature screening and included reports from the HAI database that were not included in the literature results. We de-duplicated the responsive articles using EndNote and Rayyan.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSearch Terms\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDatabase\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePubMed (Medline)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSearch Terms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e((Algeria OR Angola OR Benin OR Botswana OR \"Burkina Faso\" OR Burundi OR Cabo Verde OR Cameroon OR \"Central African Republic\" OR Chad OR Comoros OR Congo OR \"Cote d'Ivoire\" OR \"Democratic Republic of Congo\" OR \"Equatorial Guinea\" OR Eritrea OR Eswatini OR Ethiopia OR Gabon OR Gambia OR Ghana OR \"Guinea Bissau\" OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mozambique OR Namibia OR Niger OR Nigeria OR Rwanda OR \"Sao Tome and Principe\" OR Senegal OR Seychelles OR \"Sierra Leone\" OR \"South Africa\" OR \"South Sudan\" OR Togo OR Uganda OR Tanzania OR Zambia OR Zimbabwe) AND (\"medicine*\"[tiab] OR \"pharmaceutical*\" OR \"Pharmaceutical Preparations\"[Mesh]) AND (\"affordability\" or \"availability\")) AND ((\"2009\"[Date - Publication] : \"3000\"[Date - Publication]))\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDate Search Conducted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 Aug 2021\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber of Results\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1126\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDatabase\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEmbase\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSearch Terms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(('algeria' OR 'algeria'/exp OR algeria OR 'angola' OR 'angola'/exp OR angola OR 'benin' OR 'benin'/exp OR benin OR 'botswana' OR 'botswana'/exp OR botswana OR 'burkina faso'/exp OR 'burkina faso' OR 'burundi' OR 'burundi'/exp OR burundi OR cabo) AND verde OR 'cameroon' OR 'cameroon'/exp OR cameroon OR 'central african republic'/exp OR 'central african republic' OR 'chad' OR 'chad'/exp OR chad OR 'comoros' OR 'comoros'/exp OR comoros OR 'congo' OR 'congo'/exp OR congo OR 'cote divoire' OR 'democratic republic of congo' OR 'equatorial guinea'/exp OR 'equatorial guinea' OR 'eritrea' OR 'eritrea'/exp OR eritrea OR 'eswatini' OR 'eswatini'/exp OR eswatini OR 'ethiopia' OR 'ethiopia'/exp OR ethiopia OR 'gabon' OR 'gabon'/exp OR gabon OR 'gambia' OR 'gambia'/exp OR gambia OR 'ghana' OR 'ghana'/exp OR ghana OR 'guinea bissau'/exp OR 'guinea bissau' OR 'kenya' OR 'kenya'/exp OR kenya OR 'lesotho' OR 'lesotho'/exp OR lesotho OR 'liberia' OR 'liberia'/exp OR liberia OR 'madagascar' OR 'madagascar'/exp OR madagascar OR 'malawi' OR 'malawi'/exp OR malawi OR 'mali' OR 'mali'/exp OR mali OR 'mauritania' OR 'mauritania'/exp OR mauritania OR 'mauritius' OR 'mauritius'/exp OR mauritius OR 'mozambique' OR 'mozambique'/exp OR mozambique OR 'namibia' OR 'namibia'/exp OR namibia OR 'niger' OR 'niger'/exp OR niger OR 'nigeria' OR 'nigeria'/exp OR nigeria OR 'rwanda' OR 'rwanda'/exp OR rwanda OR 'sao tome and principe'/exp OR 'sao tome and principe' OR 'senegal' OR 'senegal'/exp OR senegal OR 'seychelles' OR 'seychelles'/exp OR seychelles OR 'sierra leone'/exp OR 'sierra leone' OR 'south africa'/exp OR 'south africa' OR 'south sudan'/exp OR 'south sudan' OR 'togo' OR 'togo'/exp OR togo OR 'uganda' OR 'uganda'/exp OR uganda OR 'tanzania' OR 'tanzania'/exp OR tanzania OR 'zambia' OR 'zambia'/exp OR zambia OR 'zimbabwe' OR 'zimbabwe'/exp OR zimbabwe) AND ('medicine*':ti,ab,kw OR 'pharmaceutical*':ti,ab,kw OR 'prescription drug'/exp) AND ('affordability'/exp OR 'affordability' OR 'availability'/exp OR 'availability') AND [2009\u0026ndash;2021]/py AND [english]/lim\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDate Search Conducted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 Aug 2021\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber of Results\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,220\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDatabase\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eWHO Global Index Medicus\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSearch Terms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e((mh:(vs2.002.001*)) OR medicine* OR pharmaceutical*) AND (\"affordability\" OR \"availability\") AND ((mh:( Z01.058*)) OR (collection_gim:(\"AIM\")))\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDate Search Conducted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 Aug 2021\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber of Results\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e135\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThree authors (JL, HN, and AK) independently screened each identified record by title and abstract based on the above inclusion and exclusion criteria using Rayyan.\u003csup\u003e34\u003c/sup\u003e JL independently reviewed all records and HN and AK each reviewed 50% of the responsive abstracts. Any disagreements were resolved via discussion by the review authors. Three authors (JL, HN, and AK) then independently reviewed the full text of screened in articles based on the above inclusion and exclusion criteria and entered review decision in Rayyan. JL reviewed all screened full text articles and AK and HS each reviewed 50% of the screened full text articles. Any disagreements on responsiveness were resolved via discussion by the three review authors.\u003c/p\u003e\n\u003cp\u003eData extraction was then conducted by JL. The following data elements were extracted into Excel and descriptive statistics were used to analyze the extracted data: Study ID; authors; article title; publication year; data collection year(s); journal title; country(ies) where study conducted; type of study (free text); type of study (select from descriptive, correlation, or intervention); types of medicines studied; types of facilities/locations studied; types of respondents (if applicable); availability measure(s); and affordability measure(s). The dataset is available as a supplemental file.\u003c/p\u003e\n\u003cp\u003eTypes of medicines were categorized according to the categories of medicines used in the 2021 WHO Model List of Essential Medicines (WHO Model EML). The highest level category was used for all categories, except anti-infective medicines, for which we also used the sub-categories due to the large number of medicines in the sub-categories (i.e., anthelminthics, antibacterials, antifungal medicines, antiviral medicines, antiprotozoal medicines, and medicines for ectoparasitic infections). The categories are listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Some medicines are coded to multiple categories.\u003c/p\u003e\n\u003cp\u003eThe categorization decisions were based on a review of three resources. First, we reviewed the 2021 WHO Model EML and medicines listed on the 2021 WHO Model EML were coded based on the category assigned in that list. If a medicine was not listed on the 2021 WHO Model EML, we reviewed the online WHO EML website to see if the medicine had been listed on a prior WHO EML. If so, we categorized the medicine based on category(ies) assigned in the previous WHO Model EML. If the medicine had not been listed on any previous WHO Model EML, we reviewed the MedLine Plus National Library of Medicine to inform the categorization decision. The coding decisions for medicines not listed on the 2021 WHO Model EML are listed in the supplemental file under coding notes.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCoding Scheme for Type(s) of Medicines Studied\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. from 2021 WHO Model EML\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCategory Name\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnaesthetics, Preoperative Medicines and Medical Gases\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Pain and Palliative Care\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiallergics and Medicines Used in Anaphylaxis\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntidotes and Other Substances Used in Poisonings\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnticonvulsants/Antiepileptics\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnti-Infective Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnthelminthics\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntibacterials\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntifungal medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiviral medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiprotozoal medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for ectoparasitic infections\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntimigraine Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImmunomodulators and Antineoplastics\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiparkinsonism Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines Affecting the Blood\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlood Products of Human Origin and Plasma Substitutes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCardiovascular Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDermatological Medicines (topical)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiagnostic Agents\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiseptics and Disinfectants\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiuretics\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGastrointestinal Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Endocrine Disorders\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImmunologicals\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMuscle Relaxants (peripherally-acting) and Cholinesterase Inhibitors\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOphthalmological Preparations\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Reproductive Health and Perinatal Care\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeritoneal Dialysis Solution\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Mental and Behavioural Disorders\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines Acting on the Respiratory Tract\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSolutions Correcting Water, Electrolyte and Acid-Base Disturbances\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVitamins and Minerals\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEar, Nose and Throat Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Diseases of Joints\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDental Preparations\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot specific to a particular medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003e* We coded some studies as \u0026ldquo;Not specific to a particular medicine\u0026rdquo; which was not a category in the WHO Model EML\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur searches of Medline/PubMed, EMBASE, and Global Index Medicus identified 2,481 total results (1,126 from Medline/PubMed, 1,220 from EMBASE, and 135 from Global Index Medicus). We used EndNote and Rayyan to de-duplicate the search results, resulting in 1,808 articles for abstract screening. Based on our review of article abstracts, we identified 405 abstracts as potentially meeting our criteria and were able to retrieve 310 articles for full text screening. Following full text screening, we identified 250 articles as meeting our criteria. We identified three (3) additional articles in the HAI Medicine Prices, Availability, Affordability \u0026amp; Price Components Database that met our criteria, the results of which were not published in articles already captured by our literature searches. This increased the total number of articles included to 253. During the data extraction process we further excluded 9 articles based on a secondary review, leaving a total of 244 articles in our final dataset. The full list of articles, including title, authors, journal title, and year published, is listed in the supplemental file. The record inclusion and exclusion decisions are described in the PRISMA flow diagram included as Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTypes of Studies\u003c/strong\u003e. Most articles (212/244; 87%) were descriptive studies. Only 11% (n\u0026thinsp;=\u0026thinsp;28) of all the articles were intervention studies that examined the potential effect of programmatic or other interventions on medicine availability and/or affordability. The remaining four (4) articles were reviews. Of the descriptive studies, 27% (57/212) used statistical analytical techniques to identify associations between medicine availability and/or affordability measures and other variables, such as medication adherence,\u003csup\u003e35\u003c/sup\u003e use of medicines,\u003csup\u003e36\u003c/sup\u003e or compliance with treatment guidelines.\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Locations\u003c/strong\u003e. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows the study location(s) by country. Our results included studies from 26 out of 47 (55%) countries in the WHO Africa Region. The countries with the greatest number of studies were Tanzania (50), Uganda (49), Ethiopia (35), Kenya (33), Nigeria (29), and Ghana (21). Some articles included study sites in multiple countries. The list of study sites for each article is listed in the supplemental file.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eStudy Location(s) by Country\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCountry\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. of Articles\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCountry (continued)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. of Articles\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTanzania\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBenin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUganda\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSenegal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEthiopia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBurkina Faso\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKenya\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSierra Leonne\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNigeria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMadagascar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGhana\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMali\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSouth Africa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eZimbabwe\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eZambia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBotswana\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMalawi\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGambia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCameroon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSwaziland\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDemocratic Republic of Congo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBurundi\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRwanda\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCongo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMozambique\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLesotho\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTypes of Medicines Studied\u003c/strong\u003e. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the number of articles that analyzed medicine availability and/or affordability for different categories of medicines, based on the categorization scheme used in the 2021 WHO Model EML. The categories of medicines most commonly studied were antiprotozoal medicines (100 articles) (primarily antimalarials) and antibacterials (93 articles), followed by cardiovascular medicines (70 articles), gastrointestinal medicines (66 articles), medicines for reproductive health and perinatal care (65 articles), medicines for pain and palliative care (62 articles), and medicines for endocrine disorders (62 articles). We did not identify any articles on medicines for ectoparasitic infections, peritoneal dialysis solution, or dental preparations.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTypes of Medicines Studied\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMedicine Category\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. of Articles\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMedicine Category (continued)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. of Articles\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiprotozoal medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiuretics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntibacterials\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnaesthetics, Preoperative Medicines and Medical Gases\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCardiovascular Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDermatological Medicines (topical)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGastrointestinal Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnthelminthics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Reproductive Health and Perinatal Care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVitamins and Minerals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Pain and Palliative Care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImmunologicals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Endocrine Disorders\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntifungal medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines Acting on the Respiratory Tract\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Diseases of Joints\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntimigraine Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEar, Nose and Throat Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnticonvulsants/Antiepileptics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiseptics and Disinfectants\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOphthalmological Preparations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntidotes and other Substances used in Poisonings\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for Mental and Behavioural Disorders\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlood Products of Human Origin and Plasma Substitutes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot specific to a particular medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiparkinsonism Medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiviral medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiagnostic Agents\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntiallergics and Medicines used in Anaphylaxis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMuscle Relaxants (peripherally-acting) and Cholinesterase Inhibitors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImmunomodulators and Antineoplastics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines for ectoparasitic infections\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSolutions Correcting Water, Electrolyte and Acid-base Disturbances\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeritoneal Dialysis Solution\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicines Affecting the Blood\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDental Preparations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability Measures\u003c/strong\u003e. We identified 197 articles that included studies that measured medicine availability and categorized the availability measures used into six categories. The most common measure was whether a medicine was in stock on the date of a survey (i.e., cross-sectional survey) (124 articles). This included, but was not limited to, studies that used the WHO/HAI survey methodology. The second most common measure was whether stockouts occurred during a particular time period (48 articles). Often these two measures were combined. For example, Iwu, Ncobo, et al. combined the first two measures to assess the occurrence of stockouts of six tracer vaccines in Eastern Cape, South Africa.\u003csup\u003e38\u003c/sup\u003e They assessed whether the vaccine was available on the date of a survey and in the preceding 24 months using a questionnaire, record checks, and observation. The third most common medicine availability measure was respondent self-reported availability of a particular medicine (18 articles). Aweucha, Janefrances, et al. used this approach to examine the impacts of the COVID-19 pandemic on patient access to essential medicines.\u003csup\u003e39\u003c/sup\u003e They implemented a cross-sectional survey using electronic questionnaires across 36 states of Nigeria by asking patients whether they had \u0026ldquo;Difficulty accessing essential medicines\u0026rdquo; before and/or during the COVID-19 pandemic. Six articles used a measure of whether a medicine was on a stock list only. Five articles used a measure of the amount of stock available for a particular medicine. Kusemererwa, Alban, et al. used a stock level measure to assess medicine availability in the Uganda\u0026rsquo;s public sector.\u003csup\u003e40\u003c/sup\u003e They measured facility stock levels and characterized stock as optimally stocked, understocked, or overstocked. An item was considered optimally stocked if the facility had two to five months of stock, understocked if it had less than two months, and overstocked if it had more than five months. To calculate the months of stock on hand, the authors divided the stock level on the day of the study by its average monthly consumption. We also identified three articles that used prescription refill data to inform their assessment of medicine availability. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e summarizes the primary availability methods and measures used by the studies in our review.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMedicine Availability Methods \u0026amp; Measures\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAvailability Methods\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAvailability Measures\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFacility stock surveys (e.g., identified surveyor or mystery shopper)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhether medicine was in stock on a certain date\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStock level on a certain date (e.g., stockout, low stock, medium stock, high stock)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRetrospective review of facility or system-level medicine stock data/records (e.g., paper bin cards, routine data systems)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhether medicine was included on the facility stock list\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhether stockout occurred during date range (e.g., 1, 6, or 12 months)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDaily stock levels during date range (e.g., stockout, low stock, medium stock, high stock)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrescription refill rate during date range\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient or health worker self-reported availability\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(Ask) how often certain medicines are available/unavailable based on their experience (e.g., never, rarely, sometimes, most often, always)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(Ask) whether they agree with a statement that describes the goal of consistent availability of medicines or the problem of unavailability of medicines (e.g., my facility has enough [insert name of medicine]; (2) I am limited by the unavailability of [insert name of medicine])\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAffordability Measures\u003c/strong\u003e. We identified 59 articles with studies that included measures of medicine affordability, of which the most common affordability measure compared the price of the medicine to the daily wage of the lowest paid government worker (32 articles). This is the measure used in the WHO/HAI methodology. The second most common affordability measure was patient self-reported affordability (9 articles). The methodology employed by Embrey, Vialle-Valentin, et al. included a household survey in Tanzania that asked respondents whether they \u0026ldquo;had to sell things or borrow money to pay for medicines at some time in the past\u0026rdquo; and whether the household could \u0026ldquo;usually afford to buy needed medicines.\u0026rdquo;\u003csup\u003e41\u003c/sup\u003e Oridanigo, Salgedo, and Kebene used both a self-reported/perceived affordability measure and a standardized measure (i.e., daily wages of the lowest paid government worker) to measure medicine affordability in Ethiopia.\u003csup\u003e42\u003c/sup\u003e Oyando, Njoroge, et al. conducted a patient survey in Kenya to assess affordability of hypertension care and asked patients if they did any of the following to cover hypertension care costs: \u0026ldquo;borrowing (having taken a loan), selling household items or assets (eg, livestock), and use of savings.\u0026rdquo;\u003csup\u003e43\u003c/sup\u003e Five articles reported studies that used capacity to pay or similar calculation based on individual income and expenses. Khatib, McKee, et al.\u003csup\u003e44\u003c/sup\u003e and Attaei, Khatib, et al.\u003csup\u003e45\u003c/sup\u003e characterized medicines as affordable if the combined cost was less than 20% of household capacity-to-pay. Capacity-to-pay was calculated based on the household income remaining after basic subsistence needs have been met. A smaller number of studies measured affordability by comparing medicines prices with a population-level income standard such as per capita income (4 articles), minimum wage (4 articles), or the national poverty line (1 article). For example, Khuluza and Haefele-Abah used the statutory minimum daily wage of Malawi as the affordability threshold.\u003csup\u003e46\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e summarizes the primary affordability methods and measures used by the studies in our review.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMedicine Affordability Methods \u0026amp; Measures\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAffordability Methods\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAffordability Measures\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCompare medicine prices with population-level affordability standard\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDaily wage of lowest paid government worker\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNational poverty line\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDaily minimum wage\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDaily per capita income\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCalculate percentage of actual household income spent on medicines\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePercent of actual household income spent on medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCapacity-to-pay measures (e.g., % of household income spent on medicines after covering basic subsistence needs)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-reported affordability of medicines\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsk whether the household could usually afford to buy needed medicines\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsk whether they took any steps that might indicate financial hardship to buy medicines (e.g., borrowing money, taking out a loan, selling household items or assets, or using savings intended for another purpose)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results revealed that 63% of articles with medicine availability studies (124/197) and 54% of articles with medicine affordability studies (32/59) conducted in Africa during our time period of interest used cross-sectional facility survey methodologies consistent with or similar to the WHO/HAI methodology. This shows the continued importance and impact of the WHO/HAI methodology in encouraging standardized survey designs that facilitate aggregating results from multiple surveys. This standardization allows for comparing medicine availability and affordability between countries/regions and conducting repeat surveys with the same methodology to identify changes over time.\u003c/p\u003e\n\u003cp\u003eWe also found a substantial number of studies using alternative approaches to measure medicine availability and/or affordability that may complement the WHO/HAI methodology. For example, 24% of the articles with availability studies used a retrospective review of stock records to capture longitudinal data on medicine availability. These longitudinal studies can measure availability over time and provide additional insight on seasonality or other factors that can affect medicine stock rates, such as whether low stock or stockouts occur more frequently at the end of a month/quarter or during certain times of year, for instance the rainy season. For affordability studies, 52% of the articles with affordability studies used the WHO/HAI methodology of comparing medicine prices with the daily wages of the lowest paid government worker. However, 15% of the articles with affordability studies used patient self-reported affordability measures and 8% used actual household-level income and expense data to assess affordability. Furthermore, 15% used a population-level threshold for affordability other than the wages of the lowest paid government worker, such as per capita income, minimum daily wage, or national poverty line.\u003c/p\u003e\n\u003cp\u003eOur finding that 87% of articles presented descriptive studies and only 11% presented intervention studies illustrates both the importance of descriptive studies to this topic and the need for additional intervention studies. Additional intervention studies will be critical to identifying and scaling promising approaches to improve medicine availability and affordability. The extensive use of mixed methods approaches in our results was also noteworthy. Many of the studies in our results included a supply-side medicine availability survey and some type of qualitative methods component, such as key informant interviews, questionnaires, or surveys. The Environmental Profile of a Community's Health (EPOCH) instrument used by Attaei, Khatib, et al. is a good example of a mixed method approach that used \u0026ldquo;direct observation of the physical and commercial environment and a survey of perceptions of the environment by those living in it\u0026rdquo; to assess availability and affordability blood-pressure lowering medicines in 20 countries.\u003csup\u003e47\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe most commonly studied medicines in our results were antiprotozoal medicines, including antimalarials, and antibacterials, including anti-TB medicines. Antiprotozoal medicines being the most studied category of medicines reflects the substantial burden of malaria in Africa and the important role of antimalarial medicines in reducing malaria morbidity and mortality. Antibacterials being the second most commonly studied medicine also illustrates the focus of addressing the burden of infectious diseases in Africa, including the high burden of tuberculosis in many countries in the region. However, medicines for non-communicable diseases, such as cardiovascular, reproductive health and perinatal care, gastrointestinal, and endocrine disorders, were also examined in a large number of studies, signifying the double burden of communicable and non-communicable diseases within the countries. However, our results only identified 26 articles that included medicines for immunomodulators and antineoplastics, such as anti-cancer medicines. As the burden of disease in Africa continues to shift toward non-communicable diseases, there will be an increasing need for medicine availability and affordability studies for these types of medicines. Increasing the number of countries implementing and publishing the results will also be important for regional monitoring, as our review only identified studies implemented in 26 out of 47 countries in the region.\u003c/p\u003e\n\u003cp\u003eMany studies in our results collected primary data, but a substantial number of studies relied on data collected through largescale surveys, such as the Service Availability and Readiness Assessment survey,\u003csup\u003e48\u003c/sup\u003e or accessed routine data systems with data collected and maintained by a government agency. Integrating medicine availability and affordability questions into these population-level survey instruments may present an opportunity to monitor medicine availability and affordability at the population-level at minimal additional costs. We have also seen countries publish medicine availability and distribution data on public dashboards during the COVID-19 pandemic, and these dashboards and their underlying datasets may present opportunities for collaborative medicine availability or affordability monitoring between researchers and government agencies. For example, South Africa established a COVID-19 public dashboard that showed COVID-19 vaccine administration and coverage data\u003csup\u003e49\u003c/sup\u003e and the U.S. established a medicine availability dashboard for COVID-19 therapeutics that showed stock levels at more than 33,000 public and private health facilities.\u003csup\u003e50\u003c/sup\u003e Due to the costs associated with conducting primary data collection, incorporating medicine availability and affordability questions into existing population survey questionnaires and leveraging routine data systems of ministries and departments of health may present opportunities for efficient population-level monitoring of medicine availability and affordability.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur review revealed a diversity of methodologies and measures being used to study the availability and affordability of medicines across Africa. The results showed the important role that the WHO/HAI methodology has played in standardizing medicine availability and affordability surveys across the region. They also showed the role other methodologies play in measuring medicine availability and affordability, including longitudinal studies using medicine stock record reviews and patient or health worker self-reported availability. While the majority of affordability studies used the wages of the lowest paid government worker to assess affordability, we also found a number of other affordability measures being used (e.g., minimum wage, per capita income, or poverty line). We also found other methodologies for measuring affordability, including calculating percentage of actual household income spent on medicines and/or self-reported affordability of medicines using population surveys or interviews.\u003c/p\u003e \u003cp\u003eAs the burden of non-communicable diseases increases in Africa, there will be an increasing need to focus medicine availability and affordability studies on medicines for non-communicable conditions and greater funding and focus may be needed for intervention studies to help identify systems and processes that may increase access to these medicines. Our hope is that this review and the methods and measures described herein will be a useful reference for researchers and governments in designing studies and routine monitoring systems to measure and ultimately improve the availability and affordability of medicines in the region.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eNot applicable. \u0026nbsp;This review did not involve human subjects research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable. This review did not involve human subjects research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The underlying data file is included with this manuscript as a supplemental file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: JL (Conceptualization; Methodology; Formal Analysis; Writing \u0026ndash; Original Draft); HN (Methodology; Formal Analysis; Writing \u0026ndash; Review \u0026amp; Editing); AK (Methodology; Formal Analysis; Writing \u0026ndash; Review \u0026amp; Editing); YD (Conceptualization; Methodology; Writing \u0026ndash; Review \u0026amp; Editing); AS (Conceptualization; Methodology; Writing \u0026ndash; Review \u0026amp; Editing); WO (Conceptualization; Methodology; Writing \u0026ndash; Review \u0026amp; Editing)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAttaei MW, Khatib R, McKee M, et al. 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Vaccine. 2020;38(25):4111-4118. doi:10.1016/j.vaccine.2020.04.019.\u003c/li\u003e\n\u003cli\u003eEmmanuel Awucha N, Chinelo Janefrances O, Chima Meshach A, Chiamaka Henrietta J, Ibilolia Daniel A, Esther Chidiebere N. Impact of the COVID-19 Pandemic on Consumers' Access to Essential Medicines in Nigeria. Am J Trop Med Hyg. 2020;103(4):1630-1634. doi:10.4269/ajtmh.20-0838.\u003c/li\u003e\n\u003cli\u003eKusemererwa D, Alban A, Obua OT, Trap B. An exploratory study on equity in funding allocation for essential medicines and health supplies in Uganda's public sector. BMC Health Serv Res. 2016;16(1):453. Published 2016 Aug 30. doi:10.1186/s12913-016-1698-6.\u003c/li\u003e\n\u003cli\u003eEmbrey M, Vialle-Valentin C, Dillip A, et al. Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania's Health System. PLoS One. 2016;11(11):e0164332. Published 2016 Nov 8. doi:10.1371/journal.pone.0164332.\u003c/li\u003e\n\u003cli\u003eMathewos Oridanigo E, Beyene Salgedo W, Gebissa Kebene F. Affordability of Essential Medicines and Associated Factors in Public Health Facilities of Jimma Zone, Southwest Ethiopia. Adv Pharmacol Pharm Sci. 2021;2021:6640133. Published 2021 Mar 16. doi:10.1155/2021/6640133.\u003c/li\u003e\n\u003cli\u003eOyando R, Njoroge M, Nguhiu P, et al. Patient costs of hypertension care in public health care facilities in Kenya. Int J Health Plann Manage. 2019;34(2):e1166-e1178. doi:10.1002/hpm.2752.\u003c/li\u003e\n\u003cli\u003eKhatib R, McKee M, Shannon H, et al. Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet. 2016;387(10013):61-69. doi:10.1016/S0140-6736(15)00469-9.\u003c/li\u003e\n\u003cli\u003eAttaei MW, Khatib R, McKee M, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411-e419. doi:10.1016/S2468-2667(17)30141-X.\u003c/li\u003e\n\u003cli\u003eKhuluza F, Haefele-Abah C. The availability, prices and affordability of essential medicines in Malawi: A cross-sectional study. PLoS One. 2019;14(2):e0212125. Published 2019 Feb 12. doi:10.1371/journal.pone.0212125.\u003c/li\u003e\n\u003cli\u003eAttaei MW, Khatib R, McKee M, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411-e419. doi:10.1016/S2468-2667(17)30141-X.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, Service availability and readiness assessment (SARA), https://www.who.int/data/data-collection-tools/service-availability-and-readiness-assessment-(sara).\u0026nbsp; Accessed August 26, 2022.\u003c/li\u003e\n\u003cli\u003eSouth Africa COVID-19 Public Dashboard, https://sacoronavirus.co.za/latest-vaccine-statistics/.\u0026nbsp; Accessed July 8, 2022.\u003c/li\u003e\n\u003cli\u003eU.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, COVID-19 Therapeutics Locator, https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com (last visited July 8, 2022).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Medicines, Pharmaceuticals, Availability, Affordability, Africa","lastPublishedDoi":"10.21203/rs.3.rs-2076460/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2076460/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eAccess to safe, effective, quality and affordable essential medicines has become a key agenda at national and international levels following the adoption of the Sustainable Development Goals (SDG). \u0026nbsp;This agenda is especially important in African countries where numerous studies have found high levels of medicine unavailability and unaffordability. In 2003, the World Health Organization (WHO)/ Health Action International (HAI) published a manual for assessing medicine availability and affordability. To date, there has not been a systematic study appraising medicine affordability and availability studies in the Africa region that identifies the methodologies and measures used to measure and monitor progress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e. \u003c/strong\u003e\u003c/em\u003eWe conducted a systematic scoping review of studies assessing medicine availability or affordability conducted in the WHO Africa region in the years 2009-2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003e244 articles met our eligibility criteria. A majority (87%) of the articles reported descriptive studies, while 11% reported interventional studies. More than two-thirds (68%) reported studies conducted in four countries in eastern Africa. The most commonly studied medicines were antiparasitic and anti-bacterial medicines. The most commonly used measures of medicine availability were whether a medicine was in stock on the date of a survey, whether stockouts occurred during a particular period, whether a medicine was on a stock list, amount of stock available, respondent self-reported availability and prescription refill data. \u0026nbsp;Of the 59 articles that included affordability measures, 39 compared the price of the medicine to the daily wage of the lowest paid government worker. Other affordability measures were patient self-reported affordability, capacity to pay based on individual income and expenses, and comparing medicines prices with a population-level income standard (such as minimum wage, poverty line, or per capita income).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion.\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003eOur results indicate substantial adoption of the medicine availability and affordability assessment methodology recommended by WHO/HAI, but also revealed a promising set of alternative methods and measures. Our review also indicated a need for greater focus on medicines for certain non-communicable diseases, including anti-neoplastics, greater geographic diversity in the countries where these studies are conducted, and more interventional studies to identify interventions for improving access to medicines in the region.\u003c/p\u003e","manuscriptTitle":"A systematic scoping review of medicine availability and affordability in Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-15 18:52:05","doi":"10.21203/rs.3.rs-2076460/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-16T10:27:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-28T06:25:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9473fd6b-66b6-488a-be68-50bf5de525b7","date":"2022-12-07T13:20:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f1a25358-09e4-484a-b028-2452975ae517","date":"2022-12-01T10:15:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-11-24T10:10:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-11-24T10:01:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-11-14T14:59:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-11-14T14:47:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2022-09-17T21:39:10+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":"0366cad2-7379-4884-8291-6c7c3655bc5a","owner":[],"postedDate":"November 15th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-22T15:06:39+00:00","versionOfRecord":{"articleIdentity":"rs-2076460","link":"https://doi.org/10.1186/s12913-023-10494-8","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-01-17 15:01:21","publishedOnDateReadable":"January 17th, 2024"},"versionCreatedAt":"2022-11-15 18:52:05","video":"","vorDoi":"10.1186/s12913-023-10494-8","vorDoiUrl":"https://doi.org/10.1186/s12913-023-10494-8","workflowStages":[]},"version":"v1","identity":"rs-2076460","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2076460","identity":"rs-2076460","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}