Transcript Improving Access to Essential Medicines

Improving Access to Essential
Medicines in Kenya: The Nyamira District
Revolving Drug Fund Experience:
By Dr. Elizabeth Ominde-Ogaja, Dr.
Gunter Boussery and Dr. George
Otieno
Abstract
•
•
•
Introduction: The availability and accessibility of good quality essential drugs has been a challenge for the Ministry
of Health in Kenya since the attainment of independence in 1963. The problem was particularly acute at the rural
health facility level. Attempts to address the issue resulted in the introduction of the kit-system in the early 1980s,
followed by cost-sharing around 1989. Despite these measures there were still numerous reports of stock-outs at
various public health institutions around the country.
In June 1994, the Ministry of Health sent a proposal to the Belgian Administration for Development Cooperation
requesting for assistance with the establishment of a Revolving Drug Fund (RDF) to be piloted in Western Kenya.
The main goal of the project was to “develop a new institutional framework within which an improved drug supply
system can be effected”. Further consultations resulted in the selection of Nyamira District in Nyanza Province
(Western Kenya).
Objectives: Three strategies were used in achieving the project goals:
1.
The. To establish an independent self-financing RDF through the development of a new institutional
framework.
2.
The development of improved financial and drug management systems focusing on the following areas:
Drug selection
Procurement
•
Storage and stock control
•
Distribution and
•
Accounting
To monitor the Rational Use of Drugs
•
•
3.
•
•
•
Methods:
The RDF was set up through the establishment of organizational structures, community mobilization,
building of the District Medical Stores coupled with renovation of facility stores, the Improvement of
Logistics support, capacity building of health workers at the RDF and in the health facilities, selection,
procurement and distribution of drugs and installation of an efficient management system
Results: An efficient RDF was established which was able to secure the regular supply of drugs for 24
month period a 24 month period
Introduction:
•
•
•
The availability and accessibility of good quality essential drugs has been a
challenge for the Ministry of Health in Kenya since the attainment of
independence in 1963. The problem was particularly acute at the rural
health facility level. Attempts to address the issue resulted in the
introduction of the kit-system in the early 1980s, followed by cost-sharing
around 1989. Despite these measures there were still numerous reports of
stock-outs at various public health institutions around the country.
The cost-sharing system was not a full cost-recovery scheme as the fee
levied on each item was applied in an arbitrary manner. Even with the costsharing initiative the drug supply to the health facilities left a lot to be
desired. The hospital management committees were constantly looking for
new ways to boost revenue to finance drug supply and facility
improvement.
There was no harmonization of these approaches across the country. As
the Health Sector Reform agenda got underway, it was felt that a new
approach to financing drug supply should be introduced. The Health Policy
Framework Paper of 1994 placed the supply of drugs and medical supplies
to the public health institutions high on the agenda in determining the
quality of care. It has been observed that the regular availability of
adequate supplies of drugs results in increased patient attendances and
consequently confidence in the public health services increases.
Introduction:
•
•
•
In June 1994, the Ministry of Health sent a proposal to the
Belgian Administration for Development Cooperation requesting
for assistance with the establishment of a Revolving Drug Fund
(RDF) to be piloted in Western Kenya. The main goal of the
project was to “develop a new institutional framework within
which an improved drug supply system can be effected”. Further
consultations resulted in the selection of Nyamira District in
Nyanza Province (Western Kenya).
Nyamira was chosen because it was a small district (896 sq.km)
with few health facilities. It had a population of approximately
540,000 It also had a functioning infrastructure beginning with
the district hospital as the referral level and ending with the
dispensaries as the lowest level of care. Nyamira is divided into 7
administrative divisions within which are scattered 32 health
facilities comprising 1 district hospital, 2 sub-district hospitals, 10
health centres and 19 dispensaries. The cost-sharing initiative
was also in place and the communities were already accepting of
the need to pay for health care. Finally being a tea growing area
there was a sufficient level of economic activity to support a
revolving drug fund.
The RDF Nyamira Project started on 1st February 2001 and ended
on 31st January 2004.
Project Objectives
•
Three strategies were used in achieving the project
goals:
The development of a new institutional framework
within which an improved and efficient drug supply
system could be developed. This was reflected in the
establishment of an independent self-financing RDF
The second strategy was the development of improved
financial and drug management systems focusing on
the following areas:
1.
2.
•
•
•
•
•
3.
Drug selection
Procurement
Storage and stock control
Distribution and
Accounting
Rational Use of Drugs was considered to be a key
strategy in ensuring that supplies are ordered according
to medical need.
Methods I
ADMINISTRATIVE STRUCTURE:
•
The project activities commenced with the establishment of an
administrative structure to ensure that the objectives as outlined
were met. This structure comprised the following:
• The Project Coordinating Unit headed by a Deputy Chief
Pharmacist based in the Ministry of Health headquarters in
Nairobi. This provided the link between the Ministry of Health,
the Treasury and the Project.
• The Sector Steering Committee also based in the MOH
headquarters. This organ functioned as the policy making
body taking major decisions on budgetary matters as well as
the direction of the project. Its membership comprised the
following:
• From the MOH: The Permanent Secretary, Director of
Medical Services, the Project Coordinator
• A representative from the Ministry of Finance
• A representative from the Belgian Embassy
• A representative from the Belgian Technical Cooperation
Department
Methods II
•
•
The Project Management Committee based in Nyamira
District comprising 15 members taken from the Project
Coordinator, the Project Manager, the District Health
Management Team (DHMT), facility representatives and
the BTC representatives (Country representative and
Project Advisor). Its function was to ensure the overall
and local implementation of the project
The Project Management Team also based in Nyamira
was responsible for the day-to day management of the
project. It was answerable to the DHMT. The team
comprised the Project Manager, the Project Advisor (from
BTC), the Project Coordinator. They were supported and
the Project Staff
COMMUNITY MOBILIZATION:
• This was considered to be an essential step in the project
implementation. The target population had to buy into the
programme for it to succeed. The community infrastructure
comprising organized groups such as health facility
management committees, opinion leaders, clan leaders, local
chiefs etc. was used to explain the purpose of the project to
the community
Methods III
COMMUNITY MOBILIZATION (CONTD.)
•
Divisional meetings (public meetings known locally as “barazas”
were organized by the Project Management Team. In addition
printed material in the form of posters in both English and the
local language (Gusii) were prepared and distributed. A
suggestions box was placed at each facility to allow for additional
views.
PHYSICAL INFRASTRUCUTRE:
•
The project required a state of the art storage facility. A district
medical stores was constructed with adequate warehouse space
and offices for the staff. A guest house was constructed so that
visitors to the project could get acceptable accommodations near
the project site. Storage space at rural health facilities were also
rehabilitated to an professionally acceptable standard. The work
included building of safes, repair of roofs and drainage for
capturing rain water, improving security for the drugs and
construction of waste disposal sites. The dispensing area for inpatients, out-patients and drug store facilities at the district
hospital were also renovated as appropriate.
Methods IV
DEVELOPMENT OF HUMAN RESOURCES
•
Following the secondment of MOH staff as project staff, training in the
operations of an RDF were carried out. Once completed, the staff
comprising the Project Advisor, Project Coordinator, pharmaceutical
technologist and store man had completed their training, they proceeded
to train the health workers in the district on the operations of an RDF. A
total of 240 staff including medical doctors, clinical officers, nurses
pharmacy and administrative personnel were trained.
IMPROVEMENT OF THE PROCUREMENT SYSTEM
•
The District Health Management Team (DHMT) prepared a district essential
drugs list per level of care based on the Kenya EDL in consultation with the
technical staff of the RDF. Using a procurement agent, the project
purchased the first consignment of drugs from the seed funds granted by
the Belgian Technical Cooperation. The total value of drugs and medical
supplies purchased was KShs 18 million (1 US$ = KShs 78). The first
delivery had a monetary value of KShs 5.5 million. The procured drugs
complied with all the regulatory requirements of the Pharmacy and Poisons
Board.
Methods V
DEVELOPMENT OF DRUG MANAGEMENT TOOLS
•
During the baseline survey, it was noted that the state of records in the
pharmacy and stores left a lot to be desired. MOH registers, stock and bin
cards, patients registers and exemption cards were redesigned and a
system was put in place to improve inventory control at the facility level
and the District Medical Stores (DMS). An operations manual for each
facility and a training manual was also developed. A computerized
inventory and financial management system was installed at the DMS and
the district hospital. This was based on the commercial accounting package
Quick Books and Excel.
DEVELOPMENT OF A PROJECT MANAGEMENT AND MONITORING
SYSTEM
•
The initial orders from each of the facilities were made on the approved
order forms and covered a period of 3 months. Each facility was required to
open a bank account at the beginning of the project. The drug “purchases”
were done on a cash and carry basis. Cash was not actually exchanged on
purchasing but proceeds from the sales of these drugs were banked in
these individual accounts. Later in the life of the project the accounts were
consolidated into a single account due to excessive bank charges.
Methods VI
PRICING POLICY
•
Prices were set at a level that guaranteed sustainability.
Expensive drugs prices were lowered and cheap drugs were
marked up considerably which compensated for the discounted
price of the more expensive drugs. The non-pharmaceutical items
such as wound dressings materials were difficult to price thus a
pricing policy was worked out on the basis of the procedures
being carried out. All materials required for the procedures were
included in the price. E.g. a simple wound dressing costs 25
KShs, stitching was priced at 100 KShs.
•
Vaccines, family planning anti-TB drugs were distributed free to
patients as per Government policy. In July 2002, a change in
government policy required that malaria patients be treated free
of charge.
RESULTS
•
•
•
•
The project was able to sustain a constant supply of drugs for most of
the 36 months in which the project was operational.
The cost of treating common diseases was drastically reduced
compared to the cost-sharing programme and to the private market
e.g.
Case: Adult with malaria
Px:
•
•
Sulfadoxine-Pyrimethamine (SP): 3 tabs
Paracetamol 500mg
: 18 tabs
Cost of treatment:
Cost-sharing:
Cost per drug item = KShs 20
Complete treatment = KShs 40
Total px cost = KShs 40
RDF
SP costs KShs 4 per tab = KShs 12
Paracetamol costs KShs 10 for 18
tabs
Total px cost = KShs 22
Private sector (lowest price generics, quality???):
SP costs KShs 10 per tab = KShs 30
Paracetamol 18 tabs
= KShs 36 . Total px cost = KShs 66
Results II
•
•
•
•
•
With the logistics support provided by the project, the RDF project staff were able to
deliver drugs within 24 hours of receiving the regular quarterly orders from the
facilities. Emergency orders were delivered same day as they were not so many of
them.
Staff were able to carry out intensive monitoring and evaluation to ensure that revenue
generated and drugs procured were being properly accounted for with minimal losses.
This M & E does however require a heavy investment in personnel and logistics
The project was well received by the community who expressed concern about the next
steps once the official project period ended on 31st January 2004
The management of drugs from selection, procurement, distribution showed a marked
improvement despite initial complaints about workload from the health workers. There
was a general increase in job satisfaction as reported by a majority of the health
workers. The project did however face a number of challenges especially regarding the
attitude of certain health workers who found the strict controls a burden especially
when former loop holes to leakage of drugs and revenue was closed.
Despite initial training on rational use of drugs certain irrational practices were
observed which could possibly be attributed to the absence of Standard Treatment
Guidelines in the health institutions e.g. In some institutions it was observed that the
average total cost of treating malaria in adults was 3 times the district average. Further
investigations revealed that some of the patients were being given 3 drugs such as
Quinine injection, Amodiaquine and SP in addition to the paracetamol.
Conclusions and the way forward:




It has been shown that it is possible to establish a viable RDF programme at the district
level provided there is a strong M & component in the activities
The Ministry of Health has proposed the expansion of the project into 15 districts
forming satellites around Nyamira district. This will present some major administrative
challenges. The idea has been well received as evidenced from a recently done
feasibility study. A proposal is under preparation for the Expansion Phase of the Project.
It is anticipated that the restructuring of the Kenya Medical Supply Agency will have
reached a level where it can act as the procurement agent for the RDF programme.
The rational use of drugs remains a challenge. There is a need to carry out some
comprehensive drugs use studies in order to identify problem areas. A prescription
analysis was done in 2003 and the results are awaited, but preliminary results indicate
that antibiotic use may need to be addressed. In addition the impact of introducing the
RDF on RUD will need to be assessed scientifically. The MOH is about to launch the STG
and KEDL 2003. A RUD training is being prepared in consultation with the with the
Department of Pharmacy. However RUD is not really the core business of the RDF
Programme although it was included as an activity. It is anticipated that this function
will be taken up full under the revised National Drug Policy Implementation Programme.
Another key area of concern is how to take care of the needs of the poor who cannot
afford to pay at all. The MOH is proposing to introduce the National Social Helath
Insurance Fund. Further studies will need to be done to really identify the poor and to
see how the RDF can tap into the NSHIF programme