Alliance for Health Policy and System Research, World Health Organization, Geneva, Switzerland. E-mail:
Health Policy Plan. 2013 Oct;28(7):692-704. doi: 10.1093/heapol/czs108. Epub 2012 Nov 22.
Most health system strengthening interventions ignore interconnections between systems components. In particular, complex relationships between medicines and health financing, human resources, health information and service delivery are not given sufficient consideration. As a consequence, populations' access to medicines (ATM) is addressed mainly through fragmented, often vertical approaches usually focusing on supply, unrelated to the wider issue of access to health services and interventions. The objective of this article is to embed ATM in a health system perspective. For this purpose, we perform a structured literature review: we examine existing ATM frameworks, review determinants of ATM and define at which level of the health system they are likely to occur; we analyse to which extent existing ATM frameworks take into account access constraints at different levels of the health system. Our findings suggest that ATM barriers are complex and interconnected as they occur at multiple levels of the health system. Existing ATM frameworks only partially address the full range of ATM barriers. We propose three essential paradigm shifts that take into account complex and dynamic relationships between medicines and other components of the health system. A holistic view of demand-side constraints in tandem with consideration of multiple and dynamic relationships between medicines and other health system resources should be applied; it should be recognized that determinants of ATM are rooted in national, regional and international contexts. These are schematized in a new framework proposing a health system perspective on ATM.
大多数卫生系统强化干预措施都忽略了系统组成部分之间的相互联系。特别是，药品与卫生筹资、人力资源、卫生信息和服务提供之间的复杂关系没有得到充分考虑。因此，人们获取药品（ATM）主要通过零散的、通常是垂直的方法来解决，这些方法通常侧重于供应，与更广泛的获取卫生服务和干预措施的问题无关。本文的目的是从卫生系统的角度来嵌入 ATM。为此，我们进行了结构化文献综述：我们检查了现有的 ATM 框架，审查了 ATM 的决定因素，并确定了它们可能在卫生系统的哪个层面发生；我们分析了现有的 ATM 框架在多大程度上考虑了卫生系统不同层面的获取约束。我们的研究结果表明，ATM 障碍是复杂的和相互关联的，因为它们发生在卫生系统的多个层面。现有的 ATM 框架仅部分解决了 ATM 障碍的全部范围。我们提出了三个基本的范式转变，考虑到药品与卫生系统其他组成部分之间的复杂和动态关系。应该同时考虑需求方制约因素的整体观点，并考虑药品与其他卫生系统资源之间的多种和动态关系；应该认识到 ATM 的决定因素根植于国家、区域和国际背景。这些在一个新的框架中进行了图示化，提出了一个从卫生系统角度看待 ATM 的框架。
