Agenda setting for essential medicines policy in sub-Saharan Africa: a retrospective policy analysis using Kingdon’s multiple streams model

Access to essential medicines has been identified as a significant threat to achieving UHC in sub-Saharan Africa, where an estimated one third of the global population lacks access to them. Medicines play a critical role in fulfilling the key dimensions of UHC, namely access to quality healthcare and protection from financial hardship. The importance of medicines can be traced back centuries, but the discovery of "wonder drugs" in the mid-1940s and their dramatic promotion represents a significant milestone in pharmaceutical management. The role of essential medicines in health systems has evolved tremendously, enjoying moments of favourable attention and episodes of policy uncertainty and controversy. These policy swings are driven by the interplay of institutions, ideas, and interests in the political and policy domain. The geographical access to essential medicines reflects the structural determinants of inequality, which raises the importance of the matter to the level of global politics. This makes access to medicines a matter of public policy, where policy choices have consequences on immediate and long-term status of individuals and societies. Despite the public policy nature of essential medicines and the influence of politics and power in shaping policy, public policy frameworks and policy theories are rarely applied to analyse issues in the area. The study aims to conduct a document and literature review on the medicines policy challenges experienced in sub-Saharan Africa during the primary healthcare (PHC) era. The specific objectives of the study are to apply Kingdon's model to identify the contextual factors that facilitated the emergence of the essential drugs concept under PHC, to assess the factors that motivated the issue of access to medicines to be considered as a global problem under PHC, to explain how the interaction of politics and policies shaped the implementation of medicine policies in sub-Saharan Africa during PHC, and to draw lessons and experiences from the PHC era. Kingdon's model is a public policy framework for agenda setting, which consists of three independent streams: problem stream, policy stream, and politics stream. The problem stream refers to the perceptions of problems as public matters requiring intervention, while the policy stream consists of the ongoing analyses of problems and their proposed solutions together with the debates surrounding these problems and possible responses. The politics stream is comprised of events such as swings of national mood, changes of government, and campaigns by interest groups. The study used a qualitative process tracing method to frame agenda setting for essential medicines policy, which can assist in gaining insight into causal mechanisms and add an inferential advantage that is often lacking in quantitative analysis. The study also used elements of the scoping review methods developed by Arksey and O'Malley to identify the key concepts that underpinned the agenda setting and policy formulation for medicines policy in sub-Saharan Africa. The study found that unsustainable rise in drug expenditure, inequitable access to drugs, and irrational use of drugs were considered as problems in the mid-1970s. As a policy response, the essential drugs concept was introduced. A window of opportunity presented when provision of essential drugs was identified as one of the eight components of PHC. During implementation, policy contradictions emerged as political and policy actors framed the problems and perceived the effectiveness of policy responses in a manner that was amenable to their own interests and objectives. The study concluded that effective implementation of an essential medicines policy under PHC was constrained by prioritization of trade over public health in the politics stream, inadequate systems thinking in the policy stream, and promotion of economic-oriented reforms in both the politics and policy streams. These lessons from the PHC era could prove useful in improving the approach to contemporary UHC policies.