1. SOCIAL DETERMINANTS OF ACCESS TO MEDICINES IN THREE CENTRAL AMERICAN COUNTRIES Maria Cecilia Acuna, MD, MSc

2. Overview Objective: Assess the impact of social determinants on the access to medicines Design: Cross-sectional study Setting: The study was conducted at the national level in Guatemala, Honduras, and Nicaragua. It examines both the public and private sectors. 2011 Pan American Health Organization

3. Overview Study population: A total of 2,779 households were selected through a random sample. An average of 36 public health care facilities with their respective pharmacies, 5 public warehouses, and 30 private pharmacies per country were selected through a convenience sample Intervention: Data collection conducted from December 2007 to April 2008 included household and health services surveys and review of secondary sources. Stakeholders of all 3 countries and local PAHO officers were involved in all phases of the study. Each country was a unit of study and the results were compared among them 2011 Pan American Health Organization

4. Instruments used for collecting information HouseholdsHealth facilities 800 households per country A total of 2,779 households selected through a random sample 30 public and 30 private pharmaceutical services in 5 geographic regions 1 form: household survey 17 forms Cluster sampling Convenience sampling Data collection: at least 4 weeks Data collection: 2 weeks at most

5. Concept framework Health need Perceived by the individual Not perceived by the individual Health condition Determinants of health Seek for health care (expressed demand)‏ Met demand Unmet demand A c c e s s B a rr i e r s Access Exclusion/ self exclusion from care (held demand)‏ Search for medicines Demand for medicines unmet Demand for medicines met (partial, total)‏ Demand for health care

6. Outcomes measures 2011 Pan American Health Organization Economic condition Characteristics of the household Seeking behavior/demand for care and for medicines Age Employment status Ethnic background Education level Sex Characteristics of the chief of the household

7. Results The main determinant of exclusion from access to medicines is the lack of access to institutional care (OR 4.102, CI 95%); Other determinants of access to medicines are: – the characteristics of the household (OR 0.747, CI 95%), –the head of the household being employed in the formal economy (OR 0.707, CI 95%), –the socioeconomic condition of the household (OR 0.462, CI 95%) 2011 Pan American Health Organization

8. 2011 Pan American Health Organization Key lessons learned from our work Understanding people’s behavior is key to improve access to health care and to medicines Institutional care more important than expected in the access to medicines Never underestimate the power of walking out: self exclusion from care is a strong predictor of lack of access to medicines

9. Implications of our work for implementing policies and programs to improve use of medicines, immediately and in the longer term Policies aimed at improving the access to medicines must be incorporated into a broader set of policies focused on improving access to institutional care Access to medicines depends on factors that go beyond the health sector, therefore policies aimed at improving the access to medicines must be intersectoral Social determinants shape care and medicines seeking behavior: they must be taken into account in the policy formulation process 2011 Pan American Health Organization

10. Specific studies that should be included in a future research agenda on the topic Compare access to medicines among groups with different ethnic backgrounds Further explore differences in the access to medicines between acute and chronic health conditions Identify social determinants of discrimination at the point of service Document the coverage of medicines in the packages of public and private health insurance plans in the LAC region 2011 Pan American Health Organization