Faith-based pharmaceutical supply chains and their role in African pharmaceutical systems: a qualitative systematic review

For the health system to function well, the population must have equitable access to quality, affordable pharmaceutical supplies; however, pharmaceutical systems in Africa are challenged by inadequate funding, drug stock outs and irregular supplies, a shortage of trained pharmacy personnel, and a lack of systems for drug regulation and quality. Faith-based health providers, as private, not-for-profit actors, have long complemented public sector efforts in the supply of pharmaceuticals in Africa. However, the contribution of faith-based health providers in pharmaceutical systems has not been formally studied. This study examines the nature and function of faith-based healthcare providers in improving access to pharmaceutical supplies in Africa. To do so, we conducted an exploratory qualitative systematic review to identify documents that contain information on faith-based involvement in pharmaceutical supply in Africa. The review identified 20 articles for inclusion. These articles were analyzed using thematic, narrative analysis. The analysis revealed a significant evidence gap relating to the contribution of private-not-for-profit, faith-based providers to African pharmaceutical systems. The review suggests that while faith-based drug supply organizations have existed for a long time and contribute significantly to national pharmaceutical systems, there is very little known about the nature of faith-based pharmaceutical providers and how they complement public sector pharmaceutical systems. In many contexts, faith-based involvement in pharmaceutical systems improved access for the general population and increased the supply of pharmaceuticals in national systems. Faith-based drug supply organizations also often provide pharmaceutical supplies to both rural and urban areas, often targeting rural and remote areas particularly. The review also indicates that faith-based drug supply organizations improved access to medicines and related commodities and, despite a lack of regulation in many contexts, have the potential to make a positive contribution to quality assurance of pharmaceuticals. In summary, the analysis confirmed that faith-based


Introduction
Pharmaceutical systems play an important role in healthcare delivery.2][3][4] Strengthening the pharmaceutical sector to meet population needs is important to achieving positive health outcomes. 5,6ne particularly integral component of overarching health systems, as per the World Health Organization, is the pharmaceutical system. 7Its utmost relevance stems from the vital reciprocal relationship it shares with the other pillars of health care.A notable segment bolstering these networks are faith-based healthcare providers (FBHPs) 8 .
Pharmaceutical services can be provided by either public or private providers.In Africa, private providers include a mix of private-forprofit (PFP) and private-not-for-profit (PNFP) actors -the latter includes non-government organizations (NGOs), local and international donors, and faith-based healthcare providers (FBHPs) (see Figure 1 below). 8Recently, there has been much discussion on how working with the private pharmaceutical sector and incorporating their services into the national pharmaceutical services can improve access to quality affordable medicines. 9,10Isolated reports indicate that the nature and function of FBHPs takes different forms, including drug procurement, distribution, 11 dispensing, 12 and quality assurance testing. 13,14[17] Understanding the various ways in which FBHPs are involved in drug supply chains in Africa is important for health systems strengthening.9][20][21] It is also in Africa where the most is known and published about FBHPs (in comparison with other LMICs).Within that literature, there is some mention of "faith-based" pharmaceutical services, supply chains, and networks.For example, Banda et al. produced an important report for the World Health Organization (WHO) on supply and distribution of pharmaceuticals by faithbased organizations in Sub-Saharan Africa. 15chmid et al. have also noted the presence of pharmaceutical networks and stores in many African countries. 17Others have noted that missionaries were sometimes the first providers of basic pharmaceutical stores and services in the era before modern public health systems. 13,16owever, initial scoping review shows an alarming absence of any substantive evidence about the current presence and functioning of this particular type of PNFP actor within African health systems (see Part B), although it is commonly assumed they are substantial and important. 12,22,23][26] FEBRUARY 2024 -VOL 11 ISSUE 1 In Africa, the public pharmaceutical sector faces significant challenges that often render the sector ill-equipped to meet the needs of the population. 1,27,28In many African countries, irregular supply of medicines to government health facilities is a common problem and a major barrier to achieving health equity for its population. 4,29,30Specifically, resource-poor settings are undermined by unreliable funding that leads to irregular drug supply, frequent drug stock-outs, lack of infrastructure, inefficient management, and poor regulation of medicines and related commodities. 1,4,27,31][34] In some developing countries, medicine stock-outs have interrupted patient's access to ARVs and other drugs, and undermined drug adherence. 27,30,35For example, in Tanzania, drug adherence and patient health outcomes were negatively affected by the shortage of medicines in public health facilities. 28,36Also, in Kenya, patients sometimes buy medicines from drug shops because medicines are unavailable in government facilities, while in other instances informal drug sellers are the only available source of medicines. 29These medicine stores and informal drug sellers have longer operating hours as compared to government facilities, which are often closed when their services are most needed. 29ther systemic issues also undermine drug availability.For example, the shortage of pharmaceutical professionals in health facilities is also a cause for concern 37 and may contribute to long waiting times at facilities, thereby discouraging patients from attending health facilities and increasing the likelihood of drug noncompliance and drug resistance. 28Similarly, some LMICs lack the basic infrastructure necessary to ensure pharmaceutical quality, such as sophisticated laboratories for quality assurance of pharmaceuticals and human resource expertise. 37In some developing countries, inadequate regulation means that medicines leak from the private pharmaceutical sector to the informal market, and this is of great concern as it will likely increase antimicrobial and antiviral resistance. 38he private pharmaceutical sector plays an important role in LMIC drug supply chains. 39,40No pharmaceutical system is a purely public entity because in every pharmaceutical supply chain there is some private entity involvement whether it is pharmaceutical companies producing medicines or logistics companies transporting medicines. 39,41In LMICs, it is estimated that 66% of prescribed medicines are sourced from private facilities while 35% are found in the public facilities. 2As such, pharmaceutical supply chains can be improved through partnerships between government and the private sector, 42,43 and such partnerships can increase access to quality medicines at affordable cost. 44mong these private sector actors are PNFP pharmaceutical providers that are defined as "faith-based."It has been argued that "faithbased" PNFP actors are important because they have good access in remote and rural areas where there are few pubic services 45 and because they have different drug supply sources (often importing medicines from overseas through international nongovernmental organizations (NGOs) or purchasing medicines from the local manufacturing companies or the central medical stores) -although this claim is not well supported by the available evidence. 46n the broader context of health system strengthening (HSS), understanding the interconnectedness of the WHO-proposed six building blocks is key for global health system enhancement.These building blocks encompass health service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/ governance. 7Our study emphasizes the "access to essential medicines" block, noting how its strengthening could potentially transcend to other blocks, hence enhancing the entire health system.
Despite the importance of this block, accessibility and affordability of essential drugs, specifically in LMICs, remain challenging due to an array of factors such as imbalanced supply and distribution systems, procurement inefficiencies, and exorbitant costs. 47he WHO regards access to essential medicines not as an isolated component but one intertwined with the other five building blocks. 7erefore, improvements in one aspect can induce advancements in others allowing for a more robust, responsive health system.
What is obvious from the literature is that the public pharmaceutical sector cannot provide the needed medicines and medical supplies and associated services for the whole population. 47,48Therefore, the public pharmaceutical sector must engage with faith-based drug supply organizations (FB-DSOs) to improve access to quality, affordable medicines. 22,49This can be done through tax exemption on medicines or the supply of free or subsidized drugs to faithbased organizations. 49However, the shortage of evidence on the extent, nature, and function of FBHPs involved in pharmaceutical supply chains in Africa (noted above) hinders efforts to strengthen national pharmaceutical supply systems through engagement with FBHPs.
The aim of this exploratory, qualitative, systematic, review study is to begin to fill this evidence gap by collating and synthesizing descriptive qualitative and quantitative evidence from the published literature about a) the reach of faith-based pharmaceutical supply chains, b) common characteristics of (diverse types of) faith-based pharmaceutical supply chains, and c) how faith-based actors involved in pharmaceutical supply chains fit within their broader national pharmaceutical systems.

Method
We undertook an exploratory, qualitative, systematic, literature review to explore the available literature on the nature of FB-DSOs and the role they play in pharmaceutical supply chains in Africa.The review included both qualitative and quantitative data, as a synthesis approach was necessary given the exploratory research question.To strengthen this systematic review, an initial scoping review was done to understand the existing pharmaceutical systems in LMICs and the challenges faced by these systems and possible interventions to improve their functioning.
The scoping review also served to inform the development of the search strategy for the systematic review.The search strategy was then refined based on previous searches.Standardized subject terms and natural language terms were used so that studies of the same concept using different relevant terminology would be included in the results. 50Databases searched included PubMed, EBSCOhost (Africa-wide information and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) and Web of Science.These databases were included to minimize bias and to retrieve the full range of available documents.For adequate specificity and sensitivity, search terms were grouped into three categories using Boolean operators.
The documents identified from these databases were then exported to Endnote and citation tracking of all included documents was done to identify any additional relevant documents.Only documents in English and that discussed the nature and function of FB-DSOs in drug supply chains were included (see Table 1 for the inclusion criteria).Both peerreviewed and grey literature were included. 51,52he inclusion of grey literature ensured that documents from non-academic sources were included while also minimizing bias. 51The geographic area for this study is Africa, and the names of all countries within the African continent were included in the search strategy.Only documents that provided information on financing, access (the availability, cost and stock-level of medicines and related commodities at facilities, dispensaries and warehouses), regulations, human resource, and training of FB-DSOs in pharmaceutical supply chains in Africa were included.
We used thematic analysis to analyze the data, using themes identified in the scoping review to guide the coding process.Thematic analysis is a method widely used and suitable for reviews, using wide range of source of information. 53This method is a good choice for this review since the involvement of FB-DSOs in pharmaceutical supply is not well researched. 54 data extraction table was used to record and synthesize the information extracted from the papers 55 to minimize bias while ensuring that the process is standardized throughout.All articles that met the inclusion criteria (Table

Results
The initial database search yielded 1550 documents in total.When duplicate items were excluded, this was reduced to 1189 documents.When the search was modified to screen citations by title and abstract, 1151 documents were further excluded.These articles were excluded for lack of relevance to the study, particularly those from non-African countries.A total of 38 articles were finally selected for detailed reading and analysis.Full texts were available for six of the documents, and 20 were rejected because they were not appropriate for the study.These included studies that mentioned FB-DSOs in general but did not specifically comment on pharmaceutical supply and others that considered faith-based and government drug supply services as a single entity.In total, 12 articles and documents met the inclusion criteria, and two additional documents were retrieved from citation tracking resulting in a total of 14 documents.Further searches on Google and Google Scholar yielded six extra documents from grey literature, bringing the overall total to 20 documents included in this review (Figure 2).A full presentation of each of these is provided in Table 3.

Geographic distribution of articles
The review found a good representation of studies in Africa -with included studies ranging across 14 countries (Burkina Faso, Cameroon, Ivory Coast, Mali, Malawi, Nigeria, Ghana, Zambia, Tanzania, Kenya, Uganda, Democratic Republic of Congo (DRC), Rwanda and South Africa).Ghana has the highest number of studies (6), followed by Malawi and Uganda (4), Cameroon (3), DRC and Nigeria (2) (Table 3).Two articles reported on multi-country studies: Banda et al. 15 reported on Cameroon, DRC, Ghana, Kenya, Malawi, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia; and Petersen et al. 14 reported on Cameroon, DRC, Nigeria, Kenya, Uganda, Ghana.One study reported on a case study in Kenya and Uganda, 13 while two others reported on Africa in general. 56,57nother study considered developing countries in general. 12The geographic location of the studies according to region is shown in Table 2. Note.Some studies reported on more than once country, hence the disparity in number.

Year, religion and research types
In this review, the selected studies range from 1984 to 2017, with similar findings and minimal differences in methodologies (Table 3).The results demonstrate that the bulk of the research was completed recently, indicating that this topic is increasingly being focused on and that there is a growing interest in faith-based programmes at the community level.All the FB-DSOs in the review were of the Christian faith, with no information on organizations affiliated with Islam or other religions identified.Both qualitative and quantitative studies were identified for inclusion, with methods including case studies, reports, surveys, laboratory testing, questionnaires, interviews, and observations.However, it's important to note the temporal gap since the earliest used studies go back 39 years.While these older studies provide valuable historical contexts and baselines for understanding the development and role of FB-DSOs in healthcare, it's essential to confirm that the organizations cited in studies prior to 2000 still exist today and that their information remains pertinent to the current discussions in 2023.This could be perceived as a potential weakness, as dated information might have undergone numerous transformations due to changes in local contexts, demographic shifts, policy changes, or emerging medical discoveries, thereby potentially reducing the value of these older studies.Despite this, these older papers still provide a historical perspective, basic principles, and foundational understanding which are crucial in tracing the evolution and impact of the FB-DSOs.Therefore, even with potential changes or shifts, the insights provided by these papers over time fundamentally enable a deeper understanding of the research topic under consideration.Therefore, their inclusion, despite potential weaknesses, is justified.

Characteristics of faith-based drug supply organizations
FB-DSOs are organizations affiliated to a Christian Health Association (CHA) and involved in the pharmaceutical sector, such as procurement, supply, human resource training, or quality assurance. 13CHAs are national networks of FBHPs and are common in Africa.
The supply of pharmaceuticals is part of the services that are provided by CHAs.
The  4 and Figure 3).Some of these organizations are members of the Ecumenical Pharmaceutical Network (EPN), a Christian organization supporting churches and church health systems in improving access to quality, affordable pharmaceuticals while promoting the use of medicines rationally. 56PN is reported to be involved in lobbying and advocacy, increasing access to ARVs, human resource empowerment, and fighting against antimicrobial resistance through rational drug use and consumer education. 56,57EPN has wide coverage of members including 32 CHAs and 18 FB-DSOs. 56The oldest FB-DSO identified was ECC-DOM, which was established in 1971.8 Some FB-DSOs are owned by collaborations between different denominations. 16For example, CDC is owned by the Catholic Health Service of Ghana and supplies medicines to the hospitals and clinics owned by the Catholic denomination. 19,59inancial donations from (local and international) funders is a major source of funding for FBHPs in Africa. 16This is also true for FB-DSOs as most of them benefit from donations (Table 4).In addition to donations some FB-DSOs have financed their supply chain through medicines sales 13,20 and mark ups. 59owever, many FB-DSOs also receive support from national government to improve access to medicines and related commodities (Table 4). 13,16,60Of the FB-DSOs outlined in Table 4 and Figure 3, nine were supported entirely through donor funds, while five also received national government funding, and a further nine used sales of medicines as an additional revenue stream.Certain FB-DSOs run a pharmaceutical supply chain mainly for FBHP facilities in a country, such as Malawi; 12,23 while others perform the functions of central medical stores, procurement organizations, and suppliers to public and private non-faith organizations. 13,58For example, JMS and MEDS (in Uganda and Kenya respectively) are FB-DSOs with a wide customer coverage 13 and CHAN Pharm in Nigeria supplies pharmaceuticals not only to FBHPs facilities but also to the public and the PFP pharmaceutical sector. 58he services of these FB-DSOs are present in both urban and rural areas, 12,15 but they mainly target remote and hard-to-reach areas 15 and are therefore located in rural and remote areas where government services are not readily available. 15,61FB-DSOs are generally known to supply medicines and related commodities at no cost or at no cost to the poor and at affordable prices for the rest of their patients. 12,60,62The review identified six FB-DSOs that supplied medicines at no cost, while five provided medicines free of charge only to the poor.However, the cost of pharmaceuticals supplied by some FB-DSO were reported to be higher than normal market price. 13,63

Common characteristics of faith-based drug supply organizations
This section discusses the findings with respect to access, availability and affordability, and regulation, and human resources and training in relation to the nature and function of FB-DSOs in Africa.

Access, availability, and affordability
Both JMS and MEDS are described as having better access to medicines than other pharmaceutical organizations since they usually have good stock-levels of medicines and related commodities. 135][66][67] For example, in Malawi, CHAM facilities dispense medicines for free to the poor and those who can afford to pay are charged less than what PFP facilities charge. 12,23,60Similarly, Rookes' 2010 study on FBHPs in developing countries revealed that: Treatment in (church health services) CHS facilities was in the past generally free for everyone, because the bulk of the funds came from overseas' churches. 12 addition, some FB-DSOs worked hard to improve the provision of ART and related commodities to HIV-positive patients.For instance, in Burkina Faso, a small Christian organization worked with government and donors to provide ARVs and other medicines used to treat opportunistic infections (which occur more frequently and are more severe in people with weak or depressed immune systems) for HIV-positive patients. 64Another study in Zambia reported on FB-DSOs providing ARVs for HIV-positive patients whose drug adherence was tested on non-ART medicines. 66These patients were found to be compliant to follow-up appointments and adherent to ART, irrespective of the distance they had to cover. 66For example, based on the study on ART adherence in Zambia, Carlucci et al (2008) observed: Most patients travelled 3 or more hours each way, often on foot; yet, most were able to achieve optimal adherence in their first months of therapy. 66cess to medicines and related commodities is critical in the vision of FB-DSOs and was found to be superior to most government facilities. 60,68urch facilities had significantly higher scores than other groups for drug availability.Thus, for example, there was a 90% chance of their having chloroquine, and a 70% chance of having penicillin constantly available. 68 noted minimal variations in the services provided by FBHPs.Given that FBHPs have funding support from multiple donors and national governments, they appear to offer better access to medicines and related commodities than the government sector. 23,66,67In Nigeria, for example, FBHPs were able to provide medicines and related HIV-services to patients as a result of the support from the President's Emergency Plan for AIDS Relief (PEPFAR) and other funding organizations. 67Again, in Malawi, CHAM facilities are sometimes supported by international donors or government, resulting in them being able to dispense medicines and related commodities for free to the poor or at a minimal cost. 23owever, the review revealed evidence of challenges faced by some FB-DSOs in providing accessible and affordable pharmaceuticals.For example, a reduction in support from government and donor organizations was found to result in patients paying for medicines and related commodities at FBHPs. 12,63,69A study in Burkina Faso found that the medicines dispensed and services provided by some FBHPs were unaffordable for some categories of patients, especially the poor. 69Similarly, patients seeking services at FB-DSOs in Malawi and Uganda were required to pay as a result of fluctuations in donor funding and irregular and insufficient support from government. 12,63In another example, in the Ivory Coast, services provided by FBHPs were found to be negatively affected by dwindling donor support and irregular drug supply from governments. 69

Regulation
FBHPs are involved in quality assurance for pharmaceuticals in their facilities and elsewhere. 13,14,70For example, a study that conducted testing for falsified medicines (containing the wrong pharmaceutical ingredients) and substandard medicines (containing the correct pharmaceutical ingredients but not in the correct quantity) in the pharmaceutical market in Malawi, found that all the medicines in selected facilities of FBHPs in the were of acceptable quality. 70In another study, the FBHPs were involved in quality assurance testing of medicines in the pharmaceutical market in a few African countries. 14

Human resource and training
The review also suggests that FB-DSOs are involved in training for human resources for health.For example, MEDS has worked with EPN to train pharmacy staff involved in the handling of medicines and related commodities. 13The EPN reported involvement in pharmaceutical capacity building processes to improve access to quality medicines and services and improved health outcomes. 56For example, it is reported that EPN promotes the empowerment of pharmacy personnel and other prescribers in improving rational drug use and addressing the issue of antibiotic misuse and antimicrobial resistance. 56,57etween 2011 and 2017 a total of 56 candidates from 9 countries, South Sudan, DRC, Cameroon, Kenya, Uganda, Tanzania, Ghana, Chad, and Zambia, have been supported by the ESP initiative.To date, over 90% of candidates from hospitals in disadvantaged areas were enrolled for training that led to successful completion and awarded a recognized pharmacy qualification. 57

Discussion
Our systematic review of the role of FB-DSOs in pharmaceutical supply chains in Africa identified both strengths and limitations of FB-DSOs.While published data on the role of FB-DSOs in pharmaceutical supplies in Africa is scarce, available evidence suggests that FB-DSOs in the pharmaceutical sector better serve poor and vulnerable populations and improve availability of pharmaceutical supplies in difficult-to-reach areas.Our review indicated that FB-DSOs, as a component of the private pharmaceutical sector, play a key role in health service delivery through improved access to medicines and related commodities, thereby contributing to health systems strengthening.This section describes the ways in which FB-DSOs can and do contribute to strengthening national health systems -particularly regarding access, availability and affordability, human resources, and reach -as well as some of the issues faced by FB-DSOs and their users.In addition, this section suggests some ways in which FB-DSOs can be better harnessed to strengthen national pharmaceutical systems.One major issue that impacts drug supply and affordability in LMICs is patent conflicts with manufacturers, most of whom are nonnative to African nations.Here, a landmark development in global health policy -the 2001 Doha Declaration on the TRIPS Agreementplays a significant role.This international legal instrument allows countries the flexibility to bypass patents, under the clause of compulsory licensing, when it's indispensable for public health purposes. 71This provision can greatly enhance the accessibility and reduce the costs of crucial pharmaceuticals in Africa. 71ur findings also fit into the larger global health system and agenda as established by the Sustainable Development Goals (SDGs).Particularly relevant are Goal 3.8, advocating for universal health access including accessibility to medications, and 3.b, which prioritizes Research and Development on medications crucial for LMICs. 72Consequently, FB-DSOs act as strategic tools in driving towards the realization of these health-centered SDGs on the global scale. 72

Access, affordability, and availability
As discussed above, FB-DSOs embody unique strengths with respect to access, affordability, and availability which can help to strengthen national pharmaceutical supply systems.]29 The review showed that access to medicines and related commodities is critical in the vision of FB-DSOs.and much of the evidence suggests that the faith-based sector provides better access than most government facilities. 60,62,64,68urthermore, the services of FBHPs have been found to be in full operation when the public pharmaceutical supply chain is challenged with stock-outs.For example, a CHAM facility in Malawi decided to buy medicines from the PFP pharmaceutical sector when they could not receive their supply from the CMS in time to have medicines to dispense to patients. 22In Rwanda, in times of supply stockouts at the CMS, BUFMAR is viewed as the source of supply for the public pharmaceutical supply chain, thereby complementing the national pharmaceutical supply system. 73As a result, community members may be compelled to seek healthcare from FB-DSOs, rather than government facilities. 4,28,30n LMICs, patients often must pay for medicines and pharmaceutical supplies when other services in the facilities are provided at no cost 74 because medicines are being purchased from the local PFP pharmaceutical sector 39,74 due to stock out of supplies at government facilities. 27Significantly, the review found that while FB-DSOs do also purchase medicines and related commodities from the local PFP pharmaceutical sector, they often exempt the poor patients from paying for drug supplies. 12,60or example, in Malawi and Ghana, medicines and related commodities are purchased from the local private pharmaceutical sector when there is delay or interruption in supply, and in such situations, the poor receive the medicines for free while the rest of the population pay for their medicine supply. 11,12,60,75This is important in achieving the desired health outcomes as existing evidence from LMICs have shown that improving access to medicines through fees exemption improves patient drug adherence and strengthens the health system. 76,77It also suggests that FBHPs are also making an important contribution to improving equity, and some studies found that the poor are benefiting from the FBHPs more than rich who can afford to go to the PFP sector. 78,79FB-DSOs are working toward making medicines and related commodities accessible to the poor and marginalized populations. 16,17urthermore, FB-DSOs are resilient and continue to provide services in the face of health system shocks.For example, in Ghana, CHAG facilities are usually in operation when the national health system is on strike because they believe in providing a non-stop service for populations in need. 80In another instance in Ghana, patients were referred to CHAG facilities by government stakeholders when government-employed pharmacists were on strike. 80This indicates that FB-DSOs can continue to provide services when the public sector is on strike.
In addition, FBHPs have been recognized for their contribution to the management of HIV/AIDS in Africa, especially about the drug supply system. 16,81Although this review did not focus on HIV/AIDS, a few studies in the review concentrated on FB-DSOs involvement in the supply of ARVs. 64,66,67,82From broader literature, we also know that 42.5% of all ARVs, 15.6% for malaria services, and 64.3% for TB services provided by FBHPs is funded by Global Fund. 83FBHPs also provide a significant and well-coordinated programme for HIV positive patients that are on treatment in African countries facing a high HIV burden. 84This shows that FB-DSOs play an important role in providing ARVs during a time in which the African continent faces a high burden of disease because of the HIV/AIDS epidemic. 85n the other hand, in this review, we found that some patients would have to pay for medicines in some FB-DSOs facilities. 63,69For example, patients seeking healthcare at FB-DSOs in Burkina Faso and Uganda paid for medicines because donor funding and government support were insufficient to cover the running cost of the facilities. 63,69The review also found evidence of medicines being sold at higher prices in FB-DSOs.While a study from Malawi found medicine prices at FB-DSOs were lower than the international reference price, 60 the cost of medicines at faith-based facilities in Uganda was found to be higher than the international reference price. 13,63This is likely to hinder the contribution of FB-DSOs to the national health system because the cost of medicines will serve as a barrier to access.
In addition, some FB-DSOs charge for medicines even though medicines are provided for free at government facilities. 79,86,87For example, in Uganda, FB-DSOs charge for medicines 63 while medicines are dispensed for free in public health facilities. 79This can be problematic when patients cannot afford to pay, and FB-DSOs are the only form of healthcare service available, thereby limiting access to medicines for (mainly) poor patients. 20,49nother challenge is that while many FBHPs contribute to improved access to maternal health medicines and related commodities, some health facilities had a very small or an irregular supply of medicines and related commodities for reproductive health, 63 while others did not stock contraceptive medicines or provide family planning services. 68This can be attributed to religious views concerning contraception and the association of certain contraceptives with risky behaviors. 56,88Given that access to contraceptives is an important function of any health system, the failure of some FB-DSOs to ensure this, is a significant shortcoming.

Human resources
This review also suggests that there is space to improve the contribution of FBHPs to human resource training.As noted above, EPN is working with FB-DSOs to empower pharmacy personnel through training programmes in a number of African countries. 13,56This is a significant contribution, as a lack of trained pharmacy professionals contributes to the issue of irrational drug use and incorrect drug dispensing. 57Zimbabwe has 14 mission hospitals for training nurses, 89 while in Malawi, CHAM has well-established training institutions for healthcare providers, which account for approximately 80% of the human resource for health training in Malawi. 90][93] In LMICs, the pharmaceutical supply chain is mostly managed by non-pharmacy professionals, 37 and this sometimes results in the wrong medicines being dispensed with errors in drug dosages and administration times. 94Evidence shows that training in pharmacy enables them to follow standard prescribing and dispensing patterns of pharmaceuticals to promote better Jalloh, Olivier & Whyle FEBRUARY 2024 -VOL 11 ISSUE 1 service delivery. 91,92However, only five of the 20 included papers referred to the training of pharmacy personnel. 13,14,56,57,68Some papers had very little information on training, for example, a study on Tanzanian primary healthcare only made mention of supportive supervision and training being provided for pharmacy personnel annually. 68

Reach of faith-based drug supply organizations
It is commonly assumed that FB-DSOs make a significant contribution to overcoming national pharmaceutical system challenges because they are responsible for a large proportion of drug dispensing facilities.There is also evidence from the grey literature that there are dispensaries, mostly in rural areas, across the different countries in Africa served by FB-DSOs. 90,95,96In addition, broader grey literature (not included in this review) provides evidence of the extent of FB-DSOs activity.For example, we know that in Kenya and Tanzania 15.8% and 11% of dispensaries are served by FB-DSOs, respectively. 84,97owever, while some information in the review supports this claim, the information on the extent or "reach" of FB-DSOs in the included articles is relatively limited. 63,66,69ost articles reported on the general services provided by FB-DSOs and did not provide in-depth detail on medicine supply. 66It was also often unclear whether FB-DSOs were affiliated with or owned by other religious organizations. 64,66,69,82Furthermore, the validated data for dispensaries served by FB-DSOs for some countries was unavailable because some countries use ʻprimary healthcareʼ to comprise of health centers, dispensaries, and health posts, and at the end a single figure is given for all of them. 19,73In Rwanda, for example, it is reported that BUFMAR provides 35% of primary care service. 19Also, in Ghana, it was evident that CDC contributed greatly to the pharmaceutical supply chain. 19,59,80CHAM 2019. 90ote.Researchers could not find validated data for other countries This paper has shown that FB-DSOs have the capacity to overcome the significant challenges faced by national pharmaceutical systems.In the following section, we present a few mechanisms through which this capacity can be better harnessed by national health systems -public private partnerships (PPP)s and improved regulation.

The need for public private partnership
Partnership between government and the private pharmaceutical sector (PFP and PNFP) is key in improving the pharmaceutical, supply chain and strengthening the health system in LMICs. 39,42,48,49,98Evidence from this review and wider literature shows that the collaboration between government and NGOs has been successful in several countries. 48,49,99or example, in Bangladesh, improved access and compliance to tuberculosis medicines was achieved through collaboration between government and an NGO. 99here is also evidence that partnerships between government and FBHPs helps to strengthen the pharmaceutical supply chains of FBHPs.For example, many PNFP pharmaceutical organizations buy medicines from government at subsidized rates, some PNFP organizations benefit from duty-free entry on importation of medicines, 49,100 and others receive medicines and other support from the ministry of health to provide services to poor and vulnerable populations. 22his review suggests that partnerships between government and FB-DSOs are crucial because FB-DSOs provide services to the poor and vulnerable by filling in the gap, where there are inefficiencies on the side of the public sector. 15It is also evident from the review that most of the FB-DSOs receive support from government, and in most instances, this is in the form of medicines and pharmaceutical supplies.In other words, it is the partnership between the FB-DSOs and government that enables FB-DSOs to supply medicines for free. 64,66,67For example, in Malawi, CHAM facilities dispense medicines received from government at no cost to the patient, while patients must pay for medicines procured from the private sector, except for the poor. 60The review also found that in Ghana, FBHPs procure medicines from the CMS, 23,65 enabling them to dispense these medicines to populations in need.
Available literature has shown that the informal sector is highly utilized by the poor, either because they are cheaper or the only available source of medicines that supply rural remote areas and operate for longer hours. 3Partnerships between FB-DSOs and government may also address the issue of the informal sector by ensuring that the services of FB-DSOs are available in rural and hard-toreach areas as supported by this review. 62,66vidence from several studies found that in LMICs the private pharmaceutical sector is the main source of pharmaceuticals and preferred by most patients over the public pharmaceutical sector. 8,48,92Furthermore, as noted, drug stockouts are prominent in the public sector in LMICs with less than 35% of the prescribed medicines available in public facilities, while the rest is sourced from the private pharmaceutical sector, 2 and this review shows that FBHPs have better stock of pharmaceuticals. 60,68Therefore, partnerships between government and FB-DSOs could improve access to pharmaceuticals, strengthen pharmaceutical systems and improve health outcomes.

The need for improved regulation
Regulatory standards can improve quality of care and efficiency. 41In some LMICs, however, the regulatory system for pharmaceuticals is challenged by a lack of basic infrastructure, a shortage of expertise or training facilities, and a scarcity of high-quality, standard laboratories for quality assurance of pharmaceuticals. 37vidence collected in this review indicates that the faith-based pharmaceutical sector can help national systems to overcome these challenges.For example, MEDS was involved in quality assurance of medicines and other pharmaceutical products supplied to their customers and patients. 13In another study in the review, FBHPs participated in quality assurance of medicines in the local, private pharmaceutical sector in a few African countries with support from international donors. 14vidence from the broader literature has also shown that regulating the private pharmaceutical sector is a huge task, 101 and this review showed that FB-DSOs have similar weaknesses in record keeping, quality assurance of medicines and compliance with drug regulatory bodies. 15,82he review also found that none of the FBHPs dispensing pharmaceuticals reported that these products were tested for quality assurance before being dispensed to the patients, which is particularly problematic for facilities that source their pharmaceutical supplies directly from international donors. 11,64Strengthening government monitoring and regulatory systems to ensure that essential drug lists are adhered to, medicines are quality assured and resources received by healthcare providers are accounted for, is vital. 100,102-105Detailed quality assessment of medicines supplied at FBHPs facilities is essential and will help policy makers and other stakeholders to provide the required support to maintain and improve the drug supply chain.
Finally, memoranda of understanding are an important mechanism to regulate the relationship FEBRUARY 2024 -VOL 11 ISSUE 1 between partners.However, none of the studies in the review reported on the existence of a memorandum of understanding or contract between government and FB-DSOs or between FB-DSOs and international donors.This is problematic because the presence of a contract usually specifies the duties and expectations of both parties, and this makes it possible to keep track of implementation processes. 12

Weaknesses
The paper identifies several weaknesses in the current literature regarding faith-based health providers (FBHPs) and pharmaceutical supplies.Firstly, many of the studies used in the research are outdated, which makes it difficult to assess the current situation.Secondly, there is limited literature available on the engagement of FBHPs in drugs and pharmaceutical supplies.This is concerning, given the significant role that FBHPs play in healthcare provision in lowand middle-income countries.The study also notes that research on the patient experience in healthcare and pharmaceutical service settings is lacking.This is a crucial area for research as it has been shown that patient satisfaction influences health-seeking behaviour and healthcare outcomes.Therefore, it is essential to understand how the patient experience in these settings affects healthcare-seeking behaviour and health outcomes.Furthermore, the focus of the study on Africa excludes literature on FBHPs involved in pharmaceutical supply systems in other contexts, making it challenging to generalize the findings outside Africa.As such, it is crucial to conduct research in other regions to ensure comparability of findings.

Future research
There are several areas in which future research is needed regarding FB-DSOs and their contribution to healthcare.Firstly, there is a need to focus on African countries that have functioning faith-based healthcare organizations and look at the role that FB-DSOs play in these settings.This research could examine patient experience in healthcare and pharmaceutical service settings.Research in this area could reveal insights into how patients perceive and interact with health systems, as well as how this affects healthcare-seeking behaviour and health outcomes.This research could identify gaps in care delivery and highlight opportunities to improve the delivery of healthcare services.Lastly, to ensure comparability of findings, there is a need for more research in other regions beyond Africa.This could provide valuable insights into the role of FBHPs in healthcare in different settings and help to identify best practices that could be applied more broadly.Overall, future research in these areas can provide important insights into the role of faithbased pharmaceutical organizations in healthcare provision and facilitate the development of evidence-based policies and strategies that could help to improve healthcare outcomes for millions of people across the globe.

Conclusion
Pharmaceutical systems play an important role in health systems strengthening.The pharmaceutical supply chains in Africa are challenged with inadequate financial resources, stock of pharmaceutical supplies, shortage of trained pharmacy personnel, and lack of infrastructures and a system for the for proper functioning of the drug regulatory system.
It is clear that FB-DSOs play a key role in the provision of pharmaceutical supplies and related healthcare services. 6,15,17However, very little evidence is available on their involvement in pharmaceutical supplies.This review identified a limited number of studies in countries known to have well-functioning FB-DSOs working in the pharmaceutical supply chain in Africa.The data describing the role and function of FB-DSOs in the pharmaceutical supply chain in Africa is particularly limited, an indication that further research is needed on how the engagement with FB-DSOs can contribute to health system strengthening in Africa.
Nonetheless, this review suggests that pharmaceutical supply chains in LMICs in Africa can be strengthened through partnership between FB-DSOs and public sector actors.FB-DSOs cover both urban and rural areas and often have better reach in rural and hard-to-reach areas.Also, the supply of pharmaceuticals is not limited to faith-based facilities but extends to the public and private pharmaceutical sectors as well.FB-DSOs tend to have good drug stocklevels with improved access to pharmaceutical supplies when compared to that of government facilities.They are, therefore, often able to supply pharmaceuticals at no cost, making their services well-trusted by a large proportion of the population.
However, some FB-DSOs involved in the pharmaceutical sector are faced with challenges -including financial constraints from the global recession and dwindling support from international donors -compelling facilities to introduce fees for service with significant implications for availability, affordability, and accessibility of pharmaceutical supplies.Further research on funding is required to look at the specific funding interests of donors and to outline factors leading to donor fatigue and the impact of this on beneficiaries, particularly in the context of pharmaceutical supplies in Africa.
FB-DSOs working in the pharmaceutical sector also play an important role in training pharmacy personnel to improve access to medicines through proper prescribing, dispensing, and promoting rational drug use.However, this review found limited evidence on human resource management involving FB-DSOs and suggests the need for more research in this area.Some FB-DSOs play a key role in quality assurance testing of medicines in the PFP pharmaceutical market in Africa.However, others were found to be deficient in record keeping, quality assurance of medicines and compliance with medicine regulatory bodies especially for the medicines dispensed by FB-DSOs, which are mostly received from international donors.Improved monitoring and regulation by government through partnerships with FB-DSOs and promoting rational drug use to ensure equitable and affordable access to quality medicines is critical.There is also a need for further research into the quality of medicines dispensed to patients by FB-DSOs in Africa.
While the focus of this review was on Africa, and therefore cannot be generalized to other contexts, the review confirms the important role FB-DSOs play in African pharmaceutical supply chains and their capacity to complement the national pharmaceutical system by improving access to medicines and related commodities thereby contributing to national health system strengthening.

Figure 1 .
Figure 1.Nature of the pharmaceutical system showing the position of faith-based healthcare providers

Table 2 .
Geographic distribution of included studies (Source: Author)

Region Number Distribution within region
FB-DSOs identified in the review include Joint Medical Stores (JMS) in Uganda, Mission for Essential Drugs and Supplies (MEDS) in Kenya, Christian Social Services Commission (CSSC) in Tanzania, Catholic Drug Centre (CDC) in Ghana, Christian Health Association Malawi (CHAM), Christian Health Association Nigeria (CHAN), Christian Health Association Zambia (CHAZ), Christian Health Association Sierra Leone (CHASL), Bureau des Formations Médicales Agréées du Rwanda (BUFMAR), Eglise du Christ au Congo -Direction des Oeuvres Médicales (ECC-DOM), Eglise évangélique du Cameroun (EEC) and Zimbabwe Association of Churches related Hospitals (ZACH) (Table

Table 3 .
Summary of included studies (N=20) FEBRUARY 2024 -VOL 11 ISSUE 1 FEBRUARY 2024 -VOL 11 ISSUE 1Figure 3. Mapping of DSOs in Africa Catholic Drug Centre (CDC) Ghana Established: 1983 Nature and extent: FB-DSO run and owned by Catholic church, supplying Catholic FBHPs nationally, who are said to provide supply to 36 catholic hospitals and 78 clinics of health services in Ghana.Christian Health Association Nigeria (CHAN) Established: 1979 Nature and extent: FB-DSO owned by the Catholic Bishop and Christian council of Nigeria with six drug depots for supply of medicines and related supplies across Nigeria.Joint Medical Stores (JMS) Established: 1980 Nature and extent: FB-DSO owned by Uganda Catholic and Protestant Medical Bureau supplying 14 dispensaries.Christian Social Services Commission (CSSC) Tanzania Established: 1992 Nature and extent: owned by Tanzania Episcopal Conference (TEC) and Christian council of Tanzania (CCT) who are said to serve 679 dispensaries across Tanzania.Christian Health Association of Malawi (CHAM) Establishment: 2000 Nature and extent: owned by CHA who are said to serve 12 dispensaries across Malawi.Christian Health Association Zambia (ZAC)Nature and extent: owned by CHA with a pharmaceutical supply system who are said to provide services to ~ 40% of health facilities and they are mainly present in the rural areas.Eglise évangélique du Cameroun, EEC in CameroonEstablished: 1986 Nature and extent: owned by Protestant and Catholic Churches Eglise du Christ au Congo-Direction des Oeuvres Medicale (ECC-DOM) Established: 1994 Nature and extent: owned by Protestant medical mission who are said to provide services to ~40% of health facilities in DR Congo

Zimbabwe Health Association of Churches related hospitals (ZACH) Established
: 1974Nature and extent: owned by the heads of churches in Zimbabwe with a pharmaceutical supply system who are said to provides services to ~ 45% of health facilities.FEBRUARY 2024 -VOL 11 ISSUE 1 Table 4 presents the FB-DSOs identified for this study.The FB-DSOs identified in this review were owned by various religious organizations, including: Catholic and Protestant Churches of Malawi, Rwanda and Cameroon; Catholic Bishop, Christian Council of Nigeria and the North Medical Advisory Council of Nigeria; Ghana Catholic Bishops Conference, Christian council of Ghana and Ghana Pentecostal Council; Council of Churches in Sierra Leone; Medical Committee of the Christian Council and the health department of Zambia Episcopal Conference of Zambia; Tanzania Episcopal Conference and Christian council of Tanzania; Catholic and Protestant Medical Bureau of Uganda; Christian Health Association of Kenya and Kenya Episcopal Conference; Protestant medical mission of Democratic Republic of Congo; and Head of Christian Denomination in Zimbabwe.

Table 4 .
Faith-based drug supply organizations in Africa

Name of network/ organization and country Date of establishment Ownership Known pharma supply (default self- estimated market share of linked facilities) Funding sources (all partial) References
Note.The text in italics are estimates based on facility coverage.Due to limited data, we were unable retrieve validated data on actual coverage for some FB-DSOs.FEBRUARY 2024 -VOL 11 ISSUE 1 Jalloh, Olivier & Whyle FEBRUARY 2024 -VOL 11 ISSUE 1

Table 5 .
Dispensaries served by public and FB-DSOs