BMC Health Services Research
(Accessed 8 November 2014)
http://www.biomedcentral.com/bmchealthservres/content

Research article
Frontline health workers as brokers: provider perceptions, experiences and mitigating strategies to improve access to essential medicines in South Africa
Bvudzai Priscilla Magadzire1*, Ashwin Budden2, Kim Ward13, Roger Jeffery4 and David Sanders1
Author Affiliations
BMC Health Services Research 2014, 14:520 doi:10.1186/s12913-014-0520-6
Published: 5 November 2014
Abstract (provisional)
Background
Front-line health providers have a unique role as brokers (patient advocates) between the health system and patients in ensuring access to medicines (ATM). ATM is a fundamental component of health systems. This paper examines in a South African context supply- and demand- ATM barriers from the provider perspective using a five dimensional framework: availability (fit between existing resources and clients? needs); accessibility (fit between physical location of healthcare and location of clients); accommodation (fit between the organisation of services and clients? practical circumstances); acceptability (fit between clients? and providers? mutual expectations and appropriateness of care) and affordability (fit between cost of care and ability to pay).
Methods
This cross-sectional, qualitative study uses semi-structured interviews with nurses, pharmacy personnel and doctors. Thirty-six providers were purposively recruited from six public sector Community Health Centres in two districts in the Eastern Cape Province representing both rural and urban settings. Content analysis combined structured coding and grounded theory approaches. Finally, the five dimensional framework was applied to illustrate the interconnected facets of the issue.
Results
Factors perceived to affect ATM were identified. Availability of medicines was hampered by logistical bottlenecks in the medicines supply chain; poor public transport networks affected accessibility. Organization of disease programmes meshed poorly with the needs of patients with comorbidities and circular migrants who move between provinces searching for economic opportunities, proximity to services such as social grants and shopping centres influenced where patients obtain medicines. Acceptability was affected by, for example, HIV related stigma leading patients to seek distant services. Travel costs exacerbated by the interplay of several ATM barriers influenced affordability. Providers play a brokerage role by adopting flexible prescribing and dispensing for `stable? patients and aligning clinic and social grant appointments to minimise clients? routine costs. Occasionally they reported assisting patients with transport money.
Conclusion
All five ATM barriers are important and they interact in complex ways. Context-sensitive responses which minimise treatment interruption are needed. While broad-based changes encompassing all disease programmes to improve ATM are needed, a beginning could be to assess the appropriateness, feasibility and sustainability of existing brokerage mechanisms.

Research article
Cost-effectiveness analysis in Developing Nations: A cross sectional survey about Exposure, Interest and Barriers
Jackson Musuuza, Mendel E Singer, Anna Mandalakas and Achilles Katamba
Author Affiliations
BMC Health Services Research 2014, 14:539 doi:10.1186/s12913-014-0539-8
Published: 4 November 2014
Abstract (provisional)
Background
Cost effectiveness analysis (CEA) is a useful tool for allocation of constrained resources, yet CEA methodologies are rarely taught or implemented in developing nations. We aimed to assess exposure to, and interest in CEA, and identify barriers to implementation in Uganda.
Methods
A cross-sectional survey was carried out in Uganda using a newly developed self-administered questionnaire (via online and paper based approaches), targeting the main health care actors as identified by a previous study.
Results
Overall, there was a 68% response rate, with a 92% (69/75) response rate among the paper-based respondents compared to a 40% (26/65) rate with the online respondents. Seventy eight percent (74/95) of the respondents had no exposure to CEA. None of those with a master of medicine degree had any CEA exposure, and 80% of technical officers, who are directly involved in policy formulation, had no CEA exposure. Barriers to CEA identified by more than 50% of the participants were: lack of information technology (IT) infrastructure (hardware and software); lack of local experts in the field of CEA; lack of or limited local data; limited CEA training in schools; equity or ethical issues; and lack of training grants incorporating CEA. 93% reported a lot of interest in learning to conduct CEA, and over 95% felt CEA was important for clinical decision making and policy formulation.
Conclusions
Among health care actors in Uganda, there is very limited exposure to, but substantial interest in conducting CEA and including it in clinical decision making and health care policy formation. Capacity to undertake CEA needs to be built through incorporation into medical training and use of regional approaches.