Transcript STUDY ON THE AVAILABILITY OF MEDICINES IN FOUR DISTRICTS OF UGANDA Wakiso, Kasese, Dokolo, Kalangala.

STUDY ON THE
AVAILABILITY OF MEDICINES
IN FOUR DISTRICTS OF
UGANDA
Wakiso, Kasese, Dokolo,
Kalangala
Presentation Outline
Study process summary
–
Background
–
Focus: objectives
–
Methods: data collection;
– Key findings; Objective I, II, III
Missing voices
General
recommendations
Study process summary
Background
• It is a result of the WBI regional meeting in Nairobi held
April 2011
• With focus on strengthening governance in pharmaceutical
procurement and supply management.
• A diverse group of stakeholders from the public, private
and civil society sectors from east Africa participated
• Country multistakeholder group (MSG), coordinated by
(MeTA) as a national convener formed.
• In November 2011, WBI opened a “quick wins” window
• It is intended to aid the MSG to work together to achieve
short term, measurable results by June 2012.
• It will generate meaningful results, and gain new insights
about long-term strategic goals.
• Its purpose is to strengthen the partnership of MeTA
Objectives
Overall objective:
• To examine the pharmaceutical procurement and supply
management in Uganda and suggest recommendations for
increasing availability of medicines in public health
facilities.
Specific Objectives
• To conduct a situational analysis on the availability of
essential medicines in public health facilities in in 4 districts
Uganda
• To examine the existing medicines procurement and supply
chain management system (PSCMS) in Uganda.
• To identify opportunities for effective engagement between
medicines institutions and national stakeholders in Uganda.
Key questions
General question
• what are the gaps and strengths of the pharmaceutical
procurement and supply chain management system in Uganda and
who this affects availability of medicines in the public sector.
Specific questions
• What the status of availability of relevant medicines as needed in
the public health facilities in the study areas?
• What are the factors behind the status of medicines availability and
what can been done to improve this situation?
• Is the existing medicines procurement and supply chain
management system (PSCMS) in Uganda efficient and effective?
Where are the gaps? What can be done to bridge them?
• Which opportunities for effective engagement between medicines
institutions and national stakeholders in Uganda exist? How can
they be harnessed better?
Scope
• The study was conducted in four districts;
Lamwo, kalangala, Kasese and Wakiso.
• At national level; MeTA, NDA, NMS, MoH
• Focus was procurement and supply of
essential medicines supplied under the push
and pull systems
Methods
• It was a qualitative study and employed;
– Key Informant interviews
– Records review
• Purposive sampling used to select the districts,
hospitals and Health Center IVs
• HC IIIs and IIs selected using criteria in the next
slide
• 40 health facilities participated
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4 hospitals
8 HC IVs
16 HC IIIs
12 HC IIs
Methods: selection criteria
• Proximity: Nearness to the center as a
determinant to access in terms of information
and easy to reach of requisitions and supply.
• Historical existence: Old districts with tested
systems and experience with the PSCMS.
• New district: It is assumed to be starting and
setting up systems, learning sometime relying on
the mother district.
• Hard to reach districts: Districts isolated
geographically and with unique populations.
Key findings
Key findings I
Objective 1
Availability of essential medicines in
public health centers
• General improvement in medicines availability at all levels
• But orders are met between 50% – 60% and never met 100%
• All health facilities reported experiencing stock out due to
inadequate supplies
– Antimalarial, antibiotics are never adequate
– In some cases, no adult doses for malaria are supplied; “we had to
combined children doses to treat adults” one of the health workers
reported.
– Antibiotics, drugs of non communicable diseases in short supply; “We
have resorted to mobilizing patients to organize themselves and buy
drugs for themselves”, a health worker remarked.
– TB drugs “we have spent 4 months without TB drugs” a respondent
from one of the hospitals reported. Pitocin and sutures were also
irregular.
• Concerns on the of gloves, plasters and leaking cannulas.
Availability of essential medicines in
public health centers …
• Sometimes excess supplies are made
(contraceptives and condoms) and NMS does
not withdraw them some have even expired
• Sometimes supplies of short period of expiry
are given, when rejected by health facilities it
means going without for the whole cycle
• Under push, some health centers are stuck
with drugs not used while others are stuck in
need of the same drugs
Availability of essential medicines in
public health centers …
• All the time whether NMS is supplying less or excess of
the orders, it fills in the delivery note what it has
supplied as what was ordered; “to shift responsibility
for excesses or shortages to health centers” a
respondent at one of the hospitals commented.
• Some times drugs are identified at the annual
procurement planning but struck off the list without
consultation the course of the year
• Sometimes prices change and the list is not updated
• Discrepancy notes and special orders are rarely
honored
Relevance of received medicines to the
needs of the health facilities
• The health facilities under pull system have relevant
drugs because they ask for what they need
• Those under push do not necessarily have all they need
– Some drugs are missing, others are in excess while others
are not needed
• Some health centers that were upgraded under push
have not had their kits upgraded; “we have to make
unnecessary referrals” a responded remarked.
• Equipment is not part of the supplies, “imagine HC IV
without the minimum of a BP machine!” one of the
DHOs wondered.
Timeliness in request and delivery of
medicines
• The system is robust; it is delivery to the door of the
health center.
• 4 out of the 6 cycles, delivery is timely
• Delays of between 1 – 3 weeks experienced whether in
Wakiso which is near or Kalangala which is hard to
reach.
– No reason is given by NMS unless prompted by the
districts
– Sometimes the reasons are genuine while in some cases
questionable e.g delayed supply by tenderers Vs
Computer error
• Once an item is missed in the delivery chances are you
wait for the next cycle
Making the push system relevant
• Is it one size fits all?
• Can’t the reports be used better to inform the
packaging periodically?
• How about actualizing the redistribution policy –
provide transport
– Some drugs were not redistributed because if it had to
happen staff needed to use their personal vehicles to
do so
• Isn’t it possible for districts to place special
requests to meet acute shortages at health center
II and III in some cases?
Key findings II
Objective 2
The procurement and supply chain management
system Vs medicines availability.
• It is has eased the burden of procurement and delivery
• Although with challenges, it has greatly improved
medicines availability compared to the old system
• Standardized prices across the board no matter the
districts
• General control over quality
• There is a poor quantification, which leads to
overstocking and out of stocks
• PPDA is not mindful of emergencies – the policy better
placed to deal with roads not matters of saving life
PSM…
• Districts are not consulted on the budget
allocation for medicine besides it is low; some
drugs are slightly expensive and eat up the
allocation
• What are the options if NMS has no supplies imagine 4 months without TB drugs, what
happened to the patients?
• Annual procurement plans is a good avenue for
prioritization
– But medicines are added or removed from the list
without consultation during the year.
PSM…
• The procurement does not consider medical
equipment “it is now only drugs, drugs and
drugs!!!!” one DHOs remarked.
• End user needs like physical stores, cold
chains, causal labour for loading and
offloading are usually ignored.
– Medicines are thus stacked together and while
those that need cold chains are scattered to
different places where there are freezers and are
difficult to track and control.
Key findings III
Objective 2
Opportunities for stakeholder
engagement on medicines
• The core medicines institutions are directly
involved in the processes each playing its due
mandate
– But there are concerns of poor attention BY NDA to
quality of supplies
– Focus on the laborious procurement procedures by
PPDA without consideration for saving life
• Other stakeholders are involved at the point of;
• Monitoring but at the point of supply mainly
Opportunities for stakeholder
engagement on medicines…
• There is no legal mechanism in place for CSO involvement
– Although key stakeholders are willing to discuss the processes
for improving efficiency, accountability and transparency
• Can CSOs be involved in information dissemination on
procurement processes
• The need to recognize the Civil society as a key sector and
bring it on board
– Civil society is left out on information flow across the system,
• Percentage of budgeted funds released,
• General availability of medicines at health facilities
• The gaps that need to be addressed
Missing voices
• Ministry of Trade, Tourism and Investment
– Put in place organized forums that bring all the
players on board to discuss pertinent issues
affecting the procurement and supply of
medicines
• Drug inspectors are missing in the NMS’ DHOs’
forum
General recommendations
• NMS should improve communication for effective feedback
to NMS on the performance of the push and pull systems
• An electronic requisition for the Health centers IVs and
hospitals will improve the efficiency and timely feedback
for the Units to make follow up.
• Updating the kit system to capture new information on the
essential drugs that can respond to major diseases/needs
of the health facilities.
• Conduct/facilitate processes for quarterly multi-stakeholder
assessment.
– Bring together key actors to interface with the medicines
institutions (JMS, NMS, MoH, NMS) and give feedback
General recommendations…
• Orientation of in-charges on the procurement and
supply system and involvement of other stakeholders
• Improve the consultation with the health facilities
during planning and budgeting processes.
• NMS the quality of the means used for transportation
to reduce wastes and loses.
– Appropriate packaging should used
• Why use sacks to transport drugs on water?
• Why not use safe aluminum boxes instead of sacks when
transporting drugs using Boda Boda?
• Step up budgeting to be commensurate with the needs
• NMS should stick to its planned schedules.