|dc.description.abstract||Background: access to healthcare services and medicines is a major problem in low-income countries. Despite a long history of modern healthcare practice, receiving international aid for health and the adoption of a free essential healthcare programme, access to healthcare services and medicines is still a challenge for Nepal. The Annapurna region consists of rural villages in Western Nepal with mixed demography and inadequate public resources. The region has received international aid for health, local communities are involved in health services development and the tourism sector contributes to the health sector.
Aim: the main aim of this thesis is to investigate access to and use of medicines taking into account the interconnectedness between the medicines, society, health systems and their stakeholders. It further aims to investigate access to and rational use of medicines in health facilities, households’ medicines use and the contribution of various stakeholders to access to healthcare and medicines.
Methods: this study involved a case study of the Annapurna region with Dhampus, Rivan, Ghandruk and Manang villages as subunits of the case. Field work took place in the Annapurna region in 2014. To investigate access to and use of medicines a health facility and households based study was carried out using standardised tools. Key informant interviews were held with various stakeholders to explore their contribution to access to medicines. Interviews were carried out with tourists and trekking professionals about healthcare provisions and the possible impacts of tourism on access to and use of medicines. The data obtained from the interviews, surveys and observations were analysed using qualitative and quantitative methods.
Results: the overall state of access to basic medicines in the Annapurna region was good (93% availability, 0% expired medicines, 1.04 stock-out days, free basic medicines and geographical accessibility for the majority of the people). However, the majority of health service users and households were not satisfied with the quality and quantity of free essential medicines, so they preferred to use the private sector for medicines and made out-of-pocket payment for medicines. Medicines were used inappropriately at both health facilities’ and households’ level, which undermined quality use. The Government, as the major stakeholder, was considered to be not doing enough to provide quality healthcare services. Health aid agencies provided a range of free and subsidised healthcare services and medicines while local communities contributed via donation and active involvement in the development and delivery of healthcare services. Although tourism contributed to access in a range of ways, such as raising household incomes, there was limited interaction between tourists and locals with regard to medicines.
Conclusions: this study shows that the interaction between medicines, society, health systems and their stakeholders impact on the way people access and use medicines. It shows that improving the overall state of access to medicines requires an improvement in the quality and coverage of medicines and health services, households’ quality use of medicines and public perception about health services and the quality of medicines. Such an effort should involve all stakeholders to strengthen the Nepalese healthcare delivery system.||