Nov 21, 2019 ALBERT KALANGWA - PowerPoint Presentation

Nov 21, 2019 ALBERT KALANGWA ABSTRACT 5

2019 Global Health Supply Chain Summit, Johannesburg, S. Africa Thanks to our generous sponsors

Why stock-out and expiration of medicines occur in developing countries: Case study of Uganda2019 Global Health Supply Chain Summit, Johannesburg, S. Africa Albert KalangwaMaastricht School of Management (MSM)DBA StudentDr. Desirée Knoppen, EADA Business School, Barcelona, Spain Dr. Ozlem Bak , Brunel University,London, UK

Problem statementPoor availability of health commodities is still a major challenge in developing countries (United Nations, 2013). Performance results for the Global Fund indicate that on the day of visit, 64% of health facilities have diagnostic services tracer items and 89%, 74%, and 82% of health facilities have HIV, TB, Malaria tracer medicines (The Global Fund, 2018)There is “continuous stock out” of essential medicines in Uganda (MoFPED (UG), 2015). Conversely, expiry of medicines is common in Uganda (Josephine Katabazi, et al, 2009).The BBC has recently produced a documentary suggesting that stockout of medicines in Uganda is caused by pilferage (BBC, 2019) but did not explain the concurrent expiration of medicines.2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Research objectiveTo explain why stock-out and expiration of medicines occur in developing countries by examining the relationship between collaboration, supply chain integration and supply chain performance.2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Theoretical framework Contingency theory (Scott & Davis, 2015) and middle range theorizing (Stank, Pellathy, In, Mollenkopf, & Bell, 2017)SCOR model (Supply-Chain Council, 2012)Collaboration (Cao & Zhang, 2011)Supply chain Integration (Flynn et al 2010)Supply chain performance (Rodrigues, Stank, & Lynch, 2004)Health supply chains (Kraiselburd & Yadav 2013, Privett & Gonsalvez 2014, and Yadav, 2015)Gaps in collaboration among supply chain members and gaps in supply chain integration undermine supply chain performance which exhibit as stockout, stock accumulation, and expirations in developing countries.2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Theoretical framework: Research Model2019 Global Health Supply Chain Summit, Johannesburg, S. AfricaMajor RQ: Why stock-out and expiration of medicines occur in developing countries?

Method: Research strategyEmbedded multiple case study to achieve literal and theoretical replication (Yin, 2014). Analysis within cases and across casesReplication logic: collaboration and supply chain integration determine supply chain performance disaggregated by link in the supply chain and season. Supply chains exhibiting a high level of collaboration and supply chain integration are anticipated to perform better and vice-versaUsing interviews, documents and archivesQualitative and quantitative techniquesUsing Nvivo software for Qualitative analysis2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Method: Case selectionMajor criterion: Lead supply chain agency – public owned versus private ownedCase 1: The public-sector distribution mechanism for providing Family Planning (FP) commodities which is implemented by the Government National Medical Stores for public health facilities.Case 2: The Uganda alternative distribution mechanism for providing Family Planning (FP) commodities which is implemented by a private sector agency for private sector health facilitiesThe study focuses on two RH commodities used in the management of post-partum hemorrhage – oxytocin and misoprostol.2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Preliminary findings: Review of documents, national level KIIs2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Preliminary conclusion: Why stock-out and expiration of medicines occur in developing countries2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Weak cooperation undermines collaborationThere are shared objectives, KPIs and processes agreed and documented through the NDP and NPSSP However, the good intention of cooperation is undermined by inadequate coordination and stakeholder commitment to the NDP and NPSSP“Not monitoring the way we are chasing the strategic objectives, then it remains in the books” – National level KI“… we spend time developing a plan and we don’t have enough time to see if we are on track …” - National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Inadequate coordination undermines collaborationStructures for coordination are in place but not workingStructures for coordination at central level include CSG, HPM TWG, MeTA, RHCS group, MCH cluster TWG, QPPU etcHowever, responsibility for implementing jointly agreed strategic actions is diffuse; many stakeholders skip periodic review meetings organized by MOH (NPSSPIII mid term review report). “In the meeting we invite over 70 people but 30 regularly attend ”– National level KIIAt the sub national (district) level, there are no health workers (pharmacists) exclusively responsible for health commodity supply chains“at the implementation level, there is no people you are going to hold responsible” – National level KII“Yes we monitor but we just but we don’t have that person to hold responsible.” – National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Introduction of new commodities (Misoprostol): example of inadequate coordination“Misoprostol has not been so much promoted by government, … It’s been more of partner driven. … because of the abuse that are associated to the use of misoprostol the government did not invest so much in it” – National level KII“The RH program envisaged that they are going to create demand. And demand was not created at that level … creating demand is not only telling people, it comes with training.”– National level KII“misoprostol may be stockout in a facility because the calibre of the health worker there has either not been trained on the use of misoprostol and therefore they are just not using it at that level …” – National level KII“There was first of all an overstock, … a lot of it expired. Because it was also slow moving. And because of that, the central level warehouse hesitated to buy more because of that history of expiring.” – National level KII“no one is buying right now. Initially … it came in as a one off” – National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Inadequate information sharing undermines collaboration - ReportingReporting - Demand forecasts are inaccurate because of lack of health facility-level information on (patient numbers & stock levels). “the biggest problem, we probably have right now is that the information that we get that we use is incomplete or in many cases its wrong especially if it is just sort of like consumption information” - National level KII“misoprostol also used mainly by MCH clinic, they are the ones to give you the data to use because you could easily use the stock card data but it’s not … like any other essential commodity so they are erratic, they are some ups and downs, so if the data is not coming from the clinics and its correct you are likely to have these issues. ”- National level KII“one of the successes of the HIV program is that they are able to report exactly how many cases were in the facility, which regimens they are on” - National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Inadequate information sharing undermines collaboration - Analysis and use of information“I think the biggest problem is when facilities are ordering, when they go for procurement planning they don’t do it on evidence based, they are just gut feeling, they are not prepared I think. That’s a fact, they don’t base on data. ”– National level KII“Procurement planning process, (is) not informed by data. These people just come, …, they are not coming with hard data from their cards, or hard data based on client logs.” – National level KIIWhy would the facility not be able to quantify what they need?“this is an area that has specialization as you know pharmacists that not everybody in the health centre is equipped with the way of quantifying. They are things to do with calculations using consumption data, using the demographic data, and not everyone can do that.” – National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Inadequate information sharing undermines collaboration - Information Technology“You can’t just go somewhere and say what is the stock level.” – National level KII“DHIS 2 is designed to report on tracer indicators. It’s not a facility level information management tool …. You need to go down into the registers…To capture that full structure of information. Which is not the case. ”– National level KIIThere is fragmented progressWAOS through which people report on a bimonthly and you can login and see what is happening in the system.TB WAOS which is also has the same capabilities as WAOS. For RH (including Oxytocin & Misoprostol) apart for the tracer items reported on routinely, there is no other systems for the other products.USAID is supporting development of an integrated ERP whereby the facility are going to be integrated with the warehouse, so that whatever is happening throughout the supply chain you can see.2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Inadequate information: Expiration of medicines not reportedThe national Health Management Information System – DHIS2 does not report on expiries.“we don’t have centrally a source that tracks expiries of commodities in general. So you are not going to get except maybe through surveys, you will not get routine data coming in” – National level KII“when it comes to stock outs, yes we have regular information, data that is coming from HMIS 105 which we can use to monitor the rate of stock out of these two products” – National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Funding shortfalls undermine SC integration (1)Per capita expenditure on medicines is $1.9 declining from baseline of $2.4 in 2015 (APSPR 2015/2016). Attributed to a reduction in Per capita Health expenditure for Uganda from $56 (NHA 2016) to $51(NHA 2018) mainly due to increase in population and devaluation of the Uganda shilling.Cost of providing a basket of essential medicines in Low and Middle-Income Countries (LMICs) ranges from $13 to $25 per capita (Wirtz, 2017 - The Lancet Commissions). 2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Funding shortfalls undermine SC integration (2)“They are supposed to buy and there is no budget.” - National level KII“Oxytocin for example will be competing with malaria commodities, it will be competing with antibiotics which are for treatment of acute conditions which appear every day at the door steps” - National level KII “We know that there is limited money, but that money has not been allocated proportionately to the case load. … The money is actually allocated based on population, yes. population is not necessarily a reflection of case load” - National level KII“You see lack of money we cannot raise it here since we have enough” - National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Inadequate storage capacity at the last mile undermines commodity flow (SC integration)Oxytocin requires cold chain storage which is not readily available;Following a government directive to store oxytocin under cold chain, “initial place of storage of oxytocin was district vaccine store because they are the ones with the fridge” - National level KIIThey would remove the items from the store and there was a bit of a shortage in terms of storage space for this item in the facilities, but that was resolved and is also still being resolved … ministry of health communicated and it said that the item should be allowed in the district vaccine store - National level KIIWhen I need it I must go to district vaccine store or if I have to use it and have it at my place that means keeping it in the wrong storage conditions which is putting workers between a rock and hard place. You can’t use it where it is in ambient temperature (non-cold chain) but also don’t have it accessible in our facility and so on. - National level KIIYou may have a situation where you have a facility not ordering for oxytocin because they don’t have the storage to store it. - National level KII2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Unconventional decisions undermine SC integrationQuantifications may not be validated. “They are just collecting, put together amalgamate them put them in one place and say these are the things to procure. … they get the procurement plans, merge them up and use it to procure.” - National level KIISuspension of stocking of (misoprostol) because a large proportion of the initial quantity procured had expired“there was a stock out not because there was no money but because NMS was hesitant to stock it.” - National level KIISuspension of stocking (oxytocin) because it was declared a cold chain itemYou may have a situation where you have a facility not ordering for oxytocin because they don’t have the storage to store it. - National level KII-Prioritization of one commodity against the other“For the low stock level of oxytocin at lower levels health center 3s, 4 it could be again lack of cold chain but 2) preference to misoprostol because it is easy to use for lower level.”- National level KIIConversely, “it is Oxytocin that every facility everyone knows it is like part of the working norm of a midwife that I must have oxytocin in the maternity ward.”- National level KII 2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Preliminary ConclusionsStock-out and expiration of medicines in developing countries occur due to gaps in collaboration and supply chain integrationCollaboration is undermined by the followingWeak cooperation Inadequate coordination Uncoordinated introduction of new commodities (Misoprostol)Inadequate information sharing includingGaps in reportingGaps in analysis and use of informationGaps in Information TechnologyExpiration of medicines not reportedSupply Chain integration is undermined by the followingFunding shortfallsInadequate storage capacity at the last mile undermines commodity flowUnconventional decisions2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

Thank you2019 Global Health Supply Chain Summit, Johannesburg, S. Africa

2019 Global Health Supply Chain Summit, Johannesburg, S. Africa Thanks to our generous sponsors