Improving access to medicines is a major healthcare challenge for low-income countries because the problem traverses health systems, society and multiple stakeholders. The Annapurna region of Nepal provides a valuable case study to investigate the interplay between medicines, society and health systems and their effects on access to and use of medicines. Government health facilities and international aid organizations provide some healthcare in the region, communities participate actively in healthcare organization and delivery, there is an important tourism sector and a mostly rural society. This study investigates access to and use of medicines through health facility and household-based studies using standardised tools and through a series of structured key informant interviews with various stakeholders in health. Overall, access to essential medicines at public health facilities was good, but this was not benefitting households as much as it should. People were using the private sector for medicines because of their perception about the quality and limited numbers of government-supplied free medicines. They utilised money from remittances and tourism, and subsidised healthcare from non-government organizations (NGOs) to access healthcare and medicines. A pluralistic healthcare system existed in the villages. Inappropriate use of medicines was found in households and was linked to the inadequate health system, socioeconomic and sociocultural practices and beliefs. Nevertheless, the often disadvantaged Dalit users said that they did not face any discrimination in access to health services and medicines. The government as the main stakeholder of health was unable to meet people’s health services and medicines needs; however, health aid agencies and the local community supported these needs to some extent. This study shows that the interconnectedness between medicines, society and health systems impacts the way people access and use medicines. Improving access to medicines requires an improvement in public’s perception about quality, actual coverage and appropriate use of medicines and health services via collaborative contributions of all stakeholders. Keywords: Access to medicines, Quality use of medicines, Health systems, Society, Nepal Background ethnic groups . Some villages of the Annapurna region The Annapurna region is a cluster of rural hilly villages have received international aid over many years for devel- spread across five districts and 57 villages development opment and delivery of health services and medicines. committees of the Western region of Nepal . It is lo- These include health post construction and the Commu- cated more than 200 km from Kathmandu and provides a nity Drug Program in Ghandruk, Indian aid for building a suitable context (case) to investigate access to and use of health post in Sikles, American Himalaya Foundation aid medicines by exploring the interconnectedness between for a health clinic in Lomangthang, a missionary NGO medicines, society, health system and its stakeholders. The run hospital in Lamjung, and health clinics in Manang region consists of rural villages with a population of more and Mustang [1–6]. Likewise, local community involve- than 120,000 made up of eleven major and some minor ment in the development and delivery of healthcare ser- vices and medicines has been an important feature in some of the villages . The major referral public hospi- * Correspondence: firstname.lastname@example.org; email@example.com tals and private healthcare providers in the Annapurna re- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500 Subang Jaya, Selangor, Malaysia gion are located in the Pokhara Valley of the Western Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 2 of 12 Development Region. Most people have to walk for sev- stakeholders of health contribute to access to medicines eral hours or days and use a locally available vehicle to or not too has not been explored yet. Thus, in this article, reach these services. Another important feature of the An- we investigate access to and use of medicines through ex- napurna region is tourism, which provides better eco- ploring the interplay between medicines, society, health nomic opportunities for people and has helped in systems and stakeholders. The objectives of this study are infrastructure development in the region [7, 8]. Tourism to assess the state of access to and use of medicines at has also served the health needs of local people through a health facility level and households level, explore the con- high altitude medical post in Manang village . tribution of health system stakeholders towards improving A pluralistic healthcare environment exists in the Anna- access to medicines and understand how society, health purna region as people use Ayurvedic medicines, herbal system and its stakeholders interact to affect access to and medicines, Tibetan medicines, faith healers and home use of medicines in the Annapurna region. based remedies. The literature show that the rural lifestyle, socio-cultural and socio-religious belief systems have af- Method fected the way people access and use medicines [10–12]. This study uses a case study approach. The whole of the Likewise, a mixed demography and socioeconomic factors Annapurna region was taken as a case and four specific such as the remittances sent by migrant workers, female villages out of 57 village development committees were se- heads of households, contributions from the families of lected as the subunits of the case. As shown in Table 1, soldiers in the Indian Army and British Army to local these villages were selected so that the results could then health systems and health literacy too, have an impact on be drawn together to yield an overall picture. The research the way people use medicines in the region [4, 5]. These setting involved four villages: Dhampus, Ghandruk and contextual factors contribute to financing of medicines, Manang (villages on or near tourist trails) and Rivan vil- healthcare seeking, access to medicines, use of traditional lage (off the tourist trail). Each of these village had either a medicines and medicine-taking [4, 5]. health post or sub health post. These villages were se- The literature also show that there is a linkage between lected purposely to achieve the study objectives. These vil- medicines and local community efforts, medicines and lages had active local community that have contributed international aid, medicines and an inadequate health sys- towards local health development, received international tem and other societal features in the Annapurna region aid for health, NGOs working in the area of health, contri- [1–5, 13–15]. However, there is a dearth of studies investi- bution via tourism and other elements which allowed the gating the interaction between medicines, society, health investigation of access to and use of medicines taking into systems and stakeholders, and the impact on access to account of the interplay between medicines, society, and use of medicines. Several important aspects of access health system and its stakeholders. to medicines are not known. The state of access to medi- cines such as physical availability, geographical accessibil- ity, affordability and quality of essential medicines and Sub health post health services are not known. Likewise, how people ac- Smallest primary healthcare unit managed by a district cess these medicines via the formal and informal health health office. It provides basic health service and limited system in the Annapurna region too is not known. (around 25) free essential medicines, run vaccination Whether people use these medicines in the right manner and reproductive health programs and other preventive has not been explored. Furthermore, whether local healthcare programs. A sub health post is headed by an Table 1 Village profiles Non-tourist village Tourist village Rivan Dhampus Ghandruk Manang Location North of Kaski North of Kaski North of Kaski North part of Manang (900 m–2000 m and above) (800 m–1600 m and above) (1000 m–3000 m and above) (3000 m and above) Population (Households) 364 620 1102 131 Average household size 3.66 4.09 3.87 4.81 Total population 1332 2537 4265 630 Source of income Agriculture and Agriculture, remittances Agriculture, remittances Agriculture and tourism remittances and tourism and tourism Access to healthcare Sub-health post, Sub-health post, Health post with pharmacy Health Post, NGO clinic, Tourist services > 2 h to reach hospital < 1 h to reach hospital service, > 4 h to reach hospital medical post, > 2 days to reach hospital K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 3 of 12 auxiliary health worker and two other staff: a village Ghandruk Community Health Post and Tangki-Manang health worker and office helper. Health Post. Data collection was carried out by the re- searcher and a research assistant. Health post Health posts are a level above sub health post and pro- 2. Semi-structured interviews on households’ vides basic healthcare and around 30 free essential medi- medicines use: cines, run vaccination and reproductive healthcare programs and other preventive health programs. A health Following the health facility based study on access to post is run by a senior auxiliary health worker, an auxiliary medicines semi-structured interviews was carried with midwife nurse, village health worker and an office helper. households in the respective four villages. The sub health post and health post remains open A semi-structured interview schedule was developed from 10:00 am to 3:00 pm and are managed by local based on a literature review of social issues in medicines health facility managed committees while resources for use in Nepal and adapting the WHO operational guide health care and staff salaries are paid by the government for level II study (Additional file 1: Appendix II). It was via the respective district health offices. All local people finalised following a pilot study in a village similar to the can access the health post and sub health post and all research site. The semi-structured interview schedule services and medicines are provided free of the cost. covered: sociodemographic profile of households, how To explore access to and use of medicines and its link- they access medicines from different sources, what prob- age with health system and society health facility based lem do they face in accessing medicines for both general surveys, households based semi-structured interviews, use and chronic health problems, how they use medi- and key informant interviews with stakeholders of health cines in households, usage of traditional medicine, and were carried out in each of these four villages. state of Dalit’s access to medicines. 1. Health facility based study on access to medicines: Sampling of the study population The Nepal Population and Housing Census 2011 was used The access to medicines health facility based study to obtain information on the population and the total form was adapted from the WHO operational guide for number of households in Dhampus, Rivan, Ghandruk and level II study (Additional file 1, The WHO level II study Manang Village Development Committee (VDCs). Based uses systematic health facility and household based sur- on the response during the household interviews and the veys to measure access to and rational use of medicines type/range of answers for interview questions in the pilot . The WHO level II indicators mainly measure a) ac- study, data saturation was achieved after six to nine inter- cess, by examining the availability and affordability of es- views. Thus, a sample target to cover more than 5% of the sential medicines (in the public sector and for the poor), households from a village by including households from b) quality, by examining the presence of expired medi- all the nine wards of a village was set. However, the final cines on pharmacy shelves, how medicines are handled number of households interviewed was adjusted based on and how well are they conserved in health facilities, and the actual interview responses and the location of Dalit c) rational use, by examining prescribing and dispensing households in that village. pattern and whether strategies such as the Standard Ward is the smallest unit of each village. From each ward Treatment Guidelines (STGs) and Essential Medicines households were selected randomly from different house- Lists (EMLs)]  are implemented or not.] . The holds’ clusters. However, if any ward contain Dalit house- health facility based access to medicines study tool was holds cluster then households were selected from those finalised following a pilot study and included three parts Dalit households cluster to include Dalit households. At (Additional file 1: Appendix I: a) interview with health least six Dalit households were selected and interviewed post incharge (person in charge of the health post) on from each village as data saturation was achieved around state of access to medicines; b) health facility survey cov- six households. A few more Dalit households were included ering various dimension of access and c) exit interviews if any village contain bigger Dalit population. with health service users and collection of information Semi-structured interview with households were car- on medicines prescribed and dispensed. ried by the researcher and research assistant in Nepal The health facility based study on access to medicines language. The interviews with households were carried was carried out in two phases, phase I in January–April out in their respective houses. Interview transcript were 2014 and phase II in November–December 2014 to cap- hand written in Nepali language and later on translated ture the medicines access situation in different fiscal quar- into English. The response to each question was read ters of the Nepal government. The study was conducted back to the household member to confirm their re- in Dhampus Sub-Health Post, Rivan Sub-Health Post, sponse. Each households interview lasted for 30 min. K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 4 of 12 Data collection period: The data collection was carried qualitative data were entered into separate sheets in out from January–April 2014. A total of 134 households Excel®. These data were entered into xls file as it would (134 houses) (Dhampus - 31 households, Rivan - 30 allow for those information to be categorized under differ- households, Ghandruk - 55 households and Manang - ent heading and subheading and analysed later on. The 18 households) were interviewed in the study. quantitative information about access to medicines (from both health facility observation and health service users 3. Key informant interviews with various stakeholders interview) was analysed using simple descriptive statistics in public health: such as frequency and average. This was presented as a percentage to reflect various indicators of access viz. avail- To know different stakeholders’ perspective on access ability, accessibility (geographical), affordability (loss of to medicines, key informants were identified and inter- pay due to illness) and acceptability, appropriate provi- viewed from the study region. Key informants identified sions of medicines storage and handling, and rational use were members of village development committee, mem- of drugs (use of medicines in accordance with the patient’s bers of health facility management committee, members clinical need, and in the right dose, frequency and dur- of female community health volunteer, government ation, and at a cost that is affordable to the patient). health workers and any other community members and The qualitative information from both the health facil- staff of NGOs/INGOs involved in public health project. ity based study and semi-structured household inter- A key informant interviews schedule was developed views was analysed using a basic thematic analysis. The following an extensive document analysis and literature final result was presented as categories/themes that review, and a reconnaissance visit of the study site. We reflected the interview. looked at documents from the WHO, Ministry of Health The transcript from the key informant interviews was Nepal and reports from different NGOs/INGOs working imported into the software QSR NVivo 10 for content in the area of healthcare delivery in Nepal. coding and analysis. The interviews were analysed as per The interviews were qualitative and in-depth, each the themes and the final result was presented as categor- interview lasting about one hour. The interviews were ies that reflected the key informants’ interviews. carried out in a flexible interview process, where topics were dealt with as they came up rather than following a Results fixed order, and so allowed the interviewees to express The section first covers access to medicines in relation his/her view in a flexible and coherent manner. Different to the Nepalese health system. It then gives an account interview guides (see Additional file 1: Appendix III) of the overall state of essential medicines in the Anna- were used depending on who the informant represented purna region and lastly the bigger picture regarding (community, government and NGO/INGO/humanitar- medicines, society, the Nepalese health system and their ian aid agency/faith based Organization). interconnectedness. Data collection Public health system in the Annapurna region and access Data collection was carried out in two phases: phase I in to medicines January–April 2014 and phase II in November–Decem- Households’ characteristics and medicines use ber 2014. The key informants interview was carried out The majority (58%) of the households in the studied vil- in their office. Fifteen key informants were interviewed. lages of the Annapurna region were headed by females. Some of the interviews were audio recorded while some Most (72%) of the household heads had either not fin- were hand written as some of the interviewees decline ished school level education or not undertaken any for- the interviews to be audio recorded. mal education. The main sources of household income in three villages (Rivan, Dhampus and Ghandruk) were a Data analysis combination of remittances and agriculture (40%). How- The Nepali language transcript of the interviews from ever, in Manang village the biggest source of income was health facility, households and key informants were the combination of business and agriculture (44%). translated into English by the researcher who is a native The overall state of access to basic medicines in the Nepali speaker fluent in both English and Nepali. In studied villages Annapurna region was good as indicated addition, the Nepali to English language translation was by high availability, no expired medicines, few stock-out reviewed and verified by professional translator during days, free medicines and better geographical accessibility the process of writing the PhD monograph and the same for the majority of health service users (Table 2). How- information has been used in this manuscript. ever, the majority of health service users expressed dis- The health facility based study contained both quantita- satisfaction with the quality of medicines and health tive and qualitative data. Both the quantitative and short services, and the limited number of medicines, and it K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 5 of 12 Table 2 Access to and rational use of medicines Table 3 Access to medicines situation in individual villages Parameters Results Dhampus SHP Ghandruk HP Manang HP Rivan SHP Physical availability (N = 19 tracer medicines) 93% Physical availability (N = 19 tracer medicines) Presence of expired medicines 0% 100% 89% 82% 100% Stock-out of medicines (in last 6 months to 1 year period) 1.04 days Presence of expired medicines People living at a distance of less than one hour 67% 0% 0% 0% 0% from the health facility Stock-out of medicines (in last 6 months to 1 year period) Waiting time for health services users in health facility 0 days 3.13 days NA 0 days Less than 30 min 100% People living at a distance of less than one hour from the health facility More than 30 min 0% 59% 53% 100% 56% Affordability (basic medicines were available for free) Waiting time for health services users in health facility Number of days of work missed due to illness 2 days Less than 30 min Loss of pay due to illness USD 5.42 100% 100% 100% 100% Acceptability Affordability (basic medicines were available for free) Satisfaction with the recent health post visit Yes No Number of days of work missed due to illness 54% 46% 1.23 days 1.42 days 1.5 days 2 days Satisfaction with the medicines 21% 79% Loss of pay due to illness Average number of medicines per prescription 1.55 USD 4.39 USD 4.59 USD 5.35 USD7.35 Percentage of medicines adequately labelled 9% Acceptability Percentage of prescription with antibiotics 39% Satisfaction with the recent health post visit Percentage of health service users who knew 96% Yes =53% Yes =95% Yes =0% Yes =69% how to use medicines dispensed to them No =47% No =5% No =100% No =31% Satisfaction with the quality of medicines was consistent throughout all the studied villages. Yes =29% Yes =37% Yes =0% Yes =20% Nevertheless, there were some variability in access to No =71% No =63% No =100% No =80% medicines across the villages. As shown in Table 3 below, Ghandruk health post had 3.13 days of stock-out Average number of medicines per prescription of medicine while Manang health post had no proper 1.58 1.47 1.5 1.68 log book of medicines availability over last six months. Percentage of medicines adequately labelled Likewise, health service users at Rivan village had high- 24% 0% 0% 13% est loss of pay of USD 7.35. Percentage of prescription with antibiotics Dalit health service users said they did not face any diffi- 41% 32% 50% 32% culties in accessing health services and medicines. Further- more, the Dalit households’ members in all of the studied Percentage of health service users who knew how to use medicines dispensed to them villages said that they do not have problem in accessing 94% 95% 100% 94% health services and medicines from health facilities because of their sociocultural background. They said that the healthcare providers’ treat them good. However, the Dalits As shown in Table 2, there were some problems with had problem with quality and coverage of health services the rational use of medicines, such as 39% of the pre- and medicines supplied by the government health facilities scription containing antibiotics, only 9% of the medi- and the need to buy medicines from private drug retailer. cines being adequately labelled (a medicine is considered Nevertheless, health services users and households from adequately labelled if it contained complete information non-Dalit group also had these problems regarding quality about the patient, the dosage, frequency and duration of and coverage of health services and medicines. medicine, instruction on how to take the medicine and how to store it) none of the health facilities having STGs We do not have any problem in accessing health and EMLs (Table 4). Again, there were variation within service and medicines from health post … But, villages. As shown in Table 4, antibiotics per prescription sometime we do not get medicines we want at the was higher in health posts of Dhampus and Manang vil- health post … [so] we have to buy medicines from the lage, and labelling of medicines was relatively better at private drug retailer in the next village. (Dalit Dhampus sub health post. However, none of the health household member Rivan village #5) services users were prescribed injections and 96% of the K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 6 of 12 Table 4 Stakeholders in health and access to medicines Stakeholders Contributions Problems and Issues Local community Provided administrative and managerial support via No such support in Rivan village due to lack of resources the health facility management committee with the village development committee Supported health post on infrastructure development, equipment and programs Supported delivery of medicines and health services via the female community health volunteer NGOs and INGOs Supported public health project and pharmacy services Lack of coordination among NGOs and INGOs and with the health system Directly provided medicines and health service via Decline in international funding and sustainability issue missionary hospitals Provided much needed secondary care, long term logistics and bureaucratic problems in implementing preventive health and rehabilitation support projects Tourism Direct support for essential medicines and health services Medicines and health use by tourists affect local people’s via donations and health camps medicine taking behaviour Infrastructure support Indirect support by providing income via tourism business Government Health System Provided limited free medicines and basic healthcare Provided vaccination, reproductive health services Problem with quality and limited number of and preventive healthcare programs free essential medicines. users knew how to use the medicines dispensed to them. they have to buy medicines from the private sector, pay- Also, only 62% of criteria for adequate handling and ing a high price for medicines that compromised their conservation condition of medicines was met by the dis- monthly budget for essential goods. pensing room with 59% of the criteria being met by the storage room. It was worst in the case of Rivan We do not have any problem in accessing health Sub-Health Post where only 12.5% of the criteria were service and medicines from health post … But, met by the storage room. sometime we do not get medicines we want at the health post … [so] we have to buy medicines from the Quality of product and services private drug retailer in the next village. (Health The quality and adequacy of health services and medicines service users Rivan village #11) were perceived to be the main problems and the central concern in all villages. During both health facilities based Most households and health service users in Dhampus, interviews and household based interviews health service Rivan and Manang said that they preferred and used pri- users expressed dissatisfaction with the quality and the vate health facilities for medicines and health services. limited number of free medicines available from govern- However, in Ghandruk village health service users said ment health facilities. People said that the free medicines that they preferred and used the government health post. are not of good quality, not powerful enough to treat their Ghandruk health post was running a community man- illness and that the free medicines available from govern- aged pharmacy in the health post where people could ment health facilities did not work for them. Some even buy approximately 100 different essential medicines said that they were like “mud” i.e. with no effect. (compared to the 25 available in the other villages). Inappropriate handling and use of medicines was the We are happy that government has provided essential problem with majority of households of the studied village medicines for free but the medicines are not of good of Annapurna region. For example, people cut their treat- quality … only a limited number of medicines are ment short as they could not buy medicines for the full provided by health post. So I think that government duration of treatment, they took allopathic medicines to- should provide good quality medicines … [and] gether with medicines from other medical traditions, they increase the number of medicines. (Dalit household believed antibiotics were powerful medicines and they also member Dhampus #5) believed that taking more medicines means more side ef- fects. Likewise, non-adherence with medicines instruc- Health service users and households also said that the tions was also found in majority of the households. This free medicines provided by the government are too few non-adherence was found especially with antibiotics, med- and do not meet their medicines needs. They said that icines requiring multiple-daily dosing and medicines that K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 7 of 12 were given for a longer duration. Consuming medicines Sources of medicines and financing without checking the expiry date was also found in the Households in the studied villages of the Annapurna re- households. gion obtained/bought various medicines such as Ayur- The reasons behind non-adherence were work burden, vedic medicines, Tibetan medicines and herbal forgetfulness, inconvenience of multiple-daily dosing, medicines from several outlets in the Pokhara Valley. side effects of certain medicines and prior experiences of They accessed faith healers and home-based remedies not complying with medicines’ schedules. through social networks and in an informal setting at the community and household level. Oh! Medicines taking is such a problem for me that [it’s Regarding allopathic medicines, people in Dhampus and such a big problem for me] I cannot say … When Rivan villages were able to get some twenty-five essential medicines are given for three or more times a day for medicines (none for chronic diseases) from the local longer period of time like 1 week … I follow the exact sub-health post and people in Ghandruk and Manang schedule for the first few days … then, as my health were able to get thirty essential medicines from local condition improves … I start working in field and I health post. Alternative resources such as a forget to take some dose of medicines … Iusually community-managed pharmacy was available in Ghan- forget to take mid-day dose of medicines. Sometime druk village, and an NGO clinic and tourist health facility when I have to work in field I skip the day time dose of were available in Manang where people could get a wide the medicines. (Household member Rivan village #3) range of medicines. Households in all the four villages ob- tained the rest of the medicines they needed, including Medicines, both currently used in the households and medicines for chronic health problems, from private drug those kept for future use, were inappropriately labelled and shops and hospital pharmacies which were located in mar- stored within children’s reach. These included antibiotics. ket towns at a distance of more than one hour or in Households in the Annapurna region were using medi- Pokhara city located at a distance of more than two hours. cines from various systems of medicine. More than half of People have to both walk and pay to use a locally available the households said that they use various types of medi- vehicle to reach these places. Households in the Anna- cines such as Ayurvedic medicines, herbal medicines, faith purna region, therefore, financed health services and med- healers, and Tibetan (Amchi) medicine, along with allo- icines through various methods such as the government pathic medicines. Some 12% of households were using a free health services and medicines, free and subsidised variety of these medicines during the time of the study. health services and medicines provided by health aid Anti-gastric powder (for hyperacidity), Ayurvedic massage agencies such as NGO clinics, missionary hospitals, and oil (for joint pain), hair oil (for hair loss), Chiraito syrup (for frequently through out-of-pocket payment. diabetes), Bojho rhizome (for sore throat) and Sancho (for body ache, common cold) were some of those commonly Stakeholders and the relationships between medicines used. In some 50% of the medicines the dose, duration and and society method of administration were not known and 43% were The public health system, local community, NGOs and used together with some form of allopathic medicines. tourism were four significant stakeholders involved in access to healthcare and medicines. The local commu- Medicines used for chronic health problems in nity, NGOs and tourism sector interacted with society households and health system at different levels in the process. Forty-two percent of the households in the studied village of The local community financially supported health post Annapurna region had members with chronic health prob- construction and equipment for Dhampus sub-health lems such as diabetes, hypertension, gastrointestinal prob- post. Similarly, the local community together with a local lems (gastritis and hyperacidity) neuromuscular problem, NGO helped Ghandruk community health post to run a and asthma. Eighty-two percent of the households with pharmacy, set up a laboratory and hire extra healthcare members who had chronic health problems were taking workers for public health projects. The local communities medicines while the remainder were not as they could not in all four villages provided administrative and managerial afford the treatment cost. Eighty-five percent of the house- support to their health post through management com- holds relied on out-of-pocket financing to buy medicines for mittees. The Female Community Health Volunteers these chronic health problems. Some 15% of households (FCHVs), who come from the local community, were used alternative sources for buying medicines for chronic directly involved in the delivery of reproductive health health problems such as free medicines from aid funded services, mass drug administration of albendazole and NGO clinics, veteran healthcare beneficiary services for the diethylcarbamazine, routine immunisation and Vitamin A Indian and the British Army veterans and their dependents, distribution for children, basic medicines through village and free medicines distributed from the government. health clinics and other public health projects. K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 8 of 12 … It all goes to the continued effort of FCHVs to of medicine such as analgesic gels, antibiotic powder, educate people about the importance of health issues medicated patches and many other dosage forms which that people now are quite supportive towards public they got from tourists during health camps. health activities. They support and participate actively The government’s free basic healthcare programme in programmes like Vitamin A campaign, provided limited free medicines and health services to immunisation campaign, albendazole medication the villages of the Annapurna region via a health post, campaign etc. But I agree that there is still some work sub-health post and primary healthcare centre. More- [more work] to do towards improving utilisation of over, the government also had programmes such as vil- family planning services. (FCHV Ghandruk #1) lage health clinics and a telemedicine service. However, the key informants from the local community said that However, there was no significant contribution from there were serious problems with the quality and cover- the local community in Rivan village in terms of dona- age of public health services and medicines in their vil- tions and other support for the health post. Further- lage, in the Annapurna region. They said that the more, the local community in Rivan did not have any government should improve the quality and coverage of economic resources such as local funds, donations from health services and medicines, and should upgrade gov- local people and tourists, and international funding that ernment health facilities so that people can get good pri- were available in tourist villages. mary healthcare services at the village level. An NGO funded by Australian donors supported a public health project and pharmacy services in Ghan- Discussion druk village. International aid-funded NGO clinics also The overall state of access to medicines in the studied vil- provided free health services and medicines in Manang lages of the Annapurna region was good in comparison to village. However, key informants also talked about issues a Nepalese study (2014) in Kathmandu, Banke and Bardia with health aid agencies such as lack of coordination districts which reported 50–77% availability and 30% stock with the government, a decline in international funding, out of medicines, and international studies in Kenya sustainability concerns, and logistics and bureaucratic (2009) with 46 days stock-out of medicines and in Jamaica problems in delivering health services in the villages of (2010) with 90 days stock-out of medicines and unafford- the Annapurna region. able medicines prices [17–19]. However, availability and stock out of medicines in the studied villages of Anna- So far as finance part is concerned we are finding it purna region was comparable to other places of Nepal hard to keep of the cost … The hospital and leprosy when compared to a study from Adhikari et al. carried out program is always struggling for funding. The in 2014 which reported 92.44% availability and 0.324 days increasing cost and patient influx … has increased our of stock-out of medicines . Study from Adhikari et al. cost and our financial reports suggests that we have to included both primary healthcare facilities and private generate some income locally to survive the hospital drug retailers and was carried out in all three geographical and manage the overall expenses … We are also region of Nepal the mountains, hills and plains while our collaborating with international donors and trying to study was carried out in the hills and mountain region get some funds but it will be a slow process. only and did not included primary health care facilities and private drug retailers due to their absence in the stud- (Staff from an INGO #1) ied villages . This improvement could be due to both better logistics provision (better physical infrastructure of Tourism provided much-needed healthcare and medi- health facilities, good walking trails, access to porters and cines for local people in Manang through a high altitude mules to carry goods and additional financial support medical aid post. Tourists also donated medicines and from VDCs) in the Annapurna region because of sustain- equipment to some of the health facilities of the Anna- able tourism and local development initiatives, and im- purna region and carried out health camps occasionally provement in the delivery of free basic healthcare services in some villages. over the years since their inception in 2007 [8, 17]. Fur- Tourism business provided income opportunities for thermore, the finding that Dalits did not appear to face households in Ghandruk, Rivan, Manang and several discrimination in accessing health services and medicines other villages of the Annapurna region and enabled shows signs of improving access. Whether this is the case people to access healthcare and other services in the pri- throughout the region is not known, but the improvement vate sector. However, health camps and medicines used in Dalits’ access may be due to better socioeconomic con- and donated by tourists also affected the way local ditions of the villagers (because of tourism business, re- people used healthcare and medicines. Households vis- mittances and access to education), targeted government ited their local health facility demanding a certain type programmes for Dalits and the better demographic profile K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 9 of 12 of Dalits in villages as non-Dalits continue to migrate to of basic medicines was good, the total number of medi- urban areas [2, 19]. cines available at the health post and sub-health post Appropriate use of medicines in the public health facil- was less because these facilities were provided with only ities of the studied villages of Annapurna region was better 18 and 25% of the essential medicines list (N = 139 med- with no injection use at health post and sub-health post icines essential medicines for primary healthcare level) level and a lower level of antibiotics prescribing compared that were meant to be used at primary healthcare level. to previous studies from Nepal [14, 20]. This maybedue The total number of medicines available at the primary to things like households’ preference and use of private healthcare level in Nepal was much smaller than the health facilities for serious illness which might require anti- range of essential medicines available at PHC level in Sri biotics and injections, the limited number of medicines Lanka [26, 27]. There is, therefore, a need to improve available at government health facilities (including very few both the quality and coverage of medicines and improve antibiotics and injections), but also importantly improving service delivery in public health facilities. awareness among Primary Health Care (PHC) workers re- Inappropriate handling and use of medicines and garding antibiotics and injection use due to the Ministry of non-adherence with medicines instructions were major is- Health’s campaigns. However, inadequate labelling and dis- sues for villagers in the studied villages of Annapurna re- pensing of medicines, deficient storage and handling of gion. These problems were rooted in socio-economic medicines, and the lack of Standard Treatment Guidelines factors, socio-cultural practices and geography. A study by and an Essential Medicines List shows that further im- Heydon with Sherpa of the Mt. Everest region of Nepal also provement in medicines use standards are needed. The in- shows that cultural practices related to health prevention appropriate handling and use of medicines noted in this and people’s perception regarding efficacy and appropriate- study were similar to the findings of the studies carried out ness of medicines are important factors when taking medi- in India, Kenya and Jamaica [18, 19, 21]. This maybebe- cines . Studies from countries such as Ghana, Jamaica, cause of the similar demographic and socioeconomic char- Uganda and India have also reported inappropriate acteristics of the households in these countries such as handling and use of medicines by households [19, 28–30]. rural locations, the majority of household heads lacking However, in Ghana’s case non-adherence was not related to formal education or not completing school level education, affordability but was related to inappropriate treatment poverty and poor social infrastructure [18, 19, 21]. practices among prescribers while in Uganda’s case it was The majority of the health service users were unsatis- related to unaffordable treatment and low availability of fied with the quality of medicines and health services, medicines [28, 29]. and the limited number of medicines and it was worst in Evidence from the Annapurna region showed that ele- the case of Manang village which was located in the ments like tourism have sociocultural effect on health- most remote place and Rivan village which is a care seeking practice and medicine taking behaviour of non-tourist village lacking access to alternative re- local people. The health aid and health camps provided sources. A study by Patel et al. also showed that South by tourists were helping the local people with medicines African consumers considered that both generic medi- and healthcare. However, it was also affecting the local cines and state supplied free essential medicines were of people’s perception and practice regarding healthcare poor quality and treated them with suspicion . The and medicines. For example, the local people demanded expressed concern in the Annapurna region about the certain type of medicines such as ointments, creams, poor quality of medicines from public health facilities capsules and antibiotics from the local health facilities as might have several complex reasons such as the sub- they received these medicines from the tourists and they standard medicines as evident from previous cases in found these medicines to be quite effective. A study by Nepal of substandard iron capsules and misoprostol tab- Susan Heydon in the Everest region also suggest that lets being distributed, people’s perception about free tourism has affect the spread of modern medicine and medicines that they are not of good quality, poor logis- healthcare seeking practice of local people . tics and infrastructure hampering medicines’ quality dur- A significant portion (42%) of households had members ing storage and distribution [23, 24]. A study by Ferrario with chronic health problems. Most used out-of-pocket et al., highlights the role of regulatory affairs affecting payment for accessing healthcare and buying essential med- the availability of quality medicines in Moldova and it icines, including medicines for chronic health problems. might have a role in Nepal case as better pharmaceutical Households used alternative resources such as NGO clinics, regulatory ecosystem favours the manufacturing and a tourist health facility, missionary hospitals and veteran procurement of quality essential medicines . Further healthcare beneficiary schemes of the Indian and the British lab based analytical studies on the quality of free medi- Army to access healthcare and medicines. Some of these re- cines are required to know more about the quality of sources are quite unique to the Annapurna region. Since free essential medicines in Nepal. Though the availability the public health system had real and perceived challenges K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 10 of 12 with quality and coverage of health services and medicines, villages so four health facilities representing five villages were the poor and vulnerable groups had difficulties accessing studied) of the Annapurna region and the health facilities lo- treatment for both chronic and other healthcare problems, cated there. Inclusion of more villages and more health facil- despite the fact that the current free basic healthcare ities could have improved the scope of the study. programme targets these groups. Furthermore, none of the studied village in this study had There is a need for the government to improve the free private drug retailers. Information about the availability of basic healthcare programme by improving the quality and private drug retailers could also have added to the quality of coverage of health services and medicines and this study the study. Furthermore, the households included in this suggests that in order to do this the government should li- study were determined based on data saturation and re- aise with local community members in the delivery sourcesavailablefor thestudy. Inclusion of more households process. The local communities have contributed signifi- as a representative of its total population could have given a cantly to the development and delivery of health services fairer representation of the minority population such as and medicines in Nepal. Studies from India, Kenya, Mali Dalits and it could have added to the richness of this study. and Cambodia also show that local communities can con- tribute to the delivery of health services (reproductive Conclusions health services, pneumonia, tuberculosis etc.) and help to This study shows that access to basic medicines in the An- improve it [30–34]. However, the extent of contribution napurna region is good. Both an improving public health from local community need to be carefully planned and system and better logistics in this tourist area have con- executed without overburdening them. Likewise, health tributed towards this outcome. However, this improve- aid agencies also contributed to the development and de- ment was not benefitting people as much as it could; livery of much-needed health services to the rural villages people were mostly using private health facilities because of the Annapurna region. However, effective implementa- they think that medicines from public health facilities are tion and coordination, and the overall functioning of aid too limited for their health needs and they have doubts funded healthcare programmes has often been contested about the quality of medicines. Inappropriate handling locally, nationally and internationally [5, 7, 35–37]. It is and use of medicines were found at both the health facility important for Nepalese health aid agencies to improve co- and household levels and this was linked with the pluralis- ordination with other agencies and bureaus, to minimise tic healthcare system, socio-economic facets of villages duplication of resources and to improve the implementa- and socio-behavioural aspects of the villagers. tion of their healthcare programmes. Tourism also con- Although the government is the main stakeholder in tributed to access to health services and medicines both health in the area, this study shows that other stakeholders directly and indirectly; but, it was limited to certain tourist such as the local community, health aid agencies and tour- villages only. By and large, the government needs to fur- ism contributed significantly to improving access to medi- ther improve the quality and coverage of health service cines and health services. Thus, to improve the public delivery with a special focus on rural villages with a poor perception about quality of medicines and the number of socio-economic profile. essential medicines and health services, and promote ap- propriate use of medicines, a joint approach involving all Strength and limitation the stakeholders such as government, community, health The main strength of this study is the exploration of aid agency and tourism sectors is required. health system, local community and other stakeholders’ role in access to medicines in detail at the village level. Additional file This study pulls information from health facilities, local households, local community members, international Additional file 1: Appendix I. Access to medicines health facility based study format. Appendix II. Semi structured interview format on agencies and local NGOs, government’s health sector “Households’ medicines use”. Appendix III. Key informants’ interview and tourism so as to know the state of access to and use format on access to medicines and stakeholders of health. (DOCX 35 kb) of medicines and how these elements are interconnected and how they contribute towards access to healthcare Abbreviations and medicines. Thus, it brings a comprehensive view on EHCS: Essential Health Care Services; INGO: International Nongovernment Organization; NGO: Nongovernment Organization; NHSSP: Nepal Health the issue of access to medicines and how different stake- Sector Support Programme; PHC: Primary Health Care; UN: United Nations; holders in health contribute towards access to healthcare VDC: Village Development Committee; WHO: (Staff from an INGO #1) World and medicines at a local level in a Nepalese village. Health Organization This study was carried out as a part of PhD project and Funding was limited to few villages of the Annapurna region. This No external funding. But, the main author who was also a PhD student study included only five villages (actually four villages but received funding for carrying out this research from the University of Otago, Manang health post was set up for both Tangki and Manang School of Pharmacy. K.C. et al. Journal of Pharmaceutical Policy and Practice (2019) 12:11 Page 11 of 12 Availability of data and materials 10. Bhattarai S, Chaudhary RP, Quave CL, Taylor RSL. The use of medicinal The datasets generated and analysed during the current study are available plants in the trans-himalayan arid zone of mustang district, Nepal. J from the corresponding author on reasonable request. Ethnobiol Ethnomed. 2010;6:14. 11. Gurung CP. Conservation for sustainable development: myth or reality? A case of the Annapurna conservation area project, Nepal. Himalaya. 1993;13(1):13. Authors’ contributions 12. Heydon S. Which medicine? Medicine-taking and changing Sherpa lives. BKC carried out study design, data collection and drafted the manuscript Himalaya. 2005;35(1):9. and finalized the mansucript. SH contributed to the study design, critically 13. Shankar PR, Kumar P, Theodore AM, Partha P, Shenoy N. A survey of drug reviewed the mansucript and revised it, and helped in the finalization of the use patterns in western Nepal. Singap Med J. 2003;44(7):352–6. mansucscipt. PN contributed to the study design, critically reviewed the 14. Shankar R, Kumar P, Rana M, Dubey A, Shenoy N. A comparative study of mansucript and revised it, and helped in the finalization of the mansucscipt. drug utilization at different levels of the primary health care system in Kaski All authors read and approved the final manuscript. district, Western Nepal. N Z Med J. 2003;116(1182):U602. 15. Adhikari SR, Pandey AR, Ghimire M, Thapa AK, Lamsal DK. Universal access Ethics approval and consent to participate to essential medicines: an evaluation of Nepal’s free health care scheme. 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Ministry of Medical Services, Ministry of Public Health and Sanitation, Kenya. search Council was shown to the participants and a formal consent was obtained Access to Essential Medicines in Kenya: A Health Facility Survey. Nairobi: from all the interviewees of health facility study, households and key informants. Ministry of Medical Services and Ministry of Public Health and Sanitation; 2009. 19. Ministry of Health of Jamaica. Pharmaceutical Situation in Jamaica: WHO Assessment of Level II - Health Facilities and Household Survey. Washington Competing interests DC: Ministry of Health of Jamaica and Pan American Health Organization, The authors would like to declare that they have no competing interest. Regional Office of the World Health Organization; 2012. However, the main author received a PhD Scholarship from the University of 20. Dahal P, Bhattarai B, Adhikari D, Shrestha R, Baral S, Shrestha N. 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