STUDY ON THE AVAILABILITY OF MEDICINES IN FOUR DISTRICTS OF UGANDA

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

2. Presentation Outline • Study process summary • Background • Focus:objectives • Methods: data collection; • Key findings; Objective I, II, III • Missing voices • General recommendations

3. Study process summary

4. 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

5. 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.

6. 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?

7. 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

8. 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 • 4 hospitals • 8 HC IVs • 16 HC IIIs • 12 HC IIs

9. 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.

10. Key findings

11. Key findings I Objective 1

12. 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.

13. 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

14. 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

15. 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.

16. 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.gdelayed supply by tenderers Vs Computer error • Once an item is missed in the delivery chances are you wait for the next cycle

17. 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?

18. Key findings II Objective 2

19. 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

20. 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.

21. 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.

22. Key findings III Objective 2

23. 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

24. 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

25. 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

26. 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

27. 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 BodaBoda? • Step up budgeting to be commensurate with the needs • NMS should stick to its planned schedules.