Improving Access to Essential Medicines in Kenya: The Nyamira District Revolving Drug Fund Experienc

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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

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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
• The. To establish an independent self-financing
  RDF through the development of a new
  institutional framework.
• 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
• 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

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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 cost-sharing 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.

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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.

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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
• 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.

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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

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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

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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 in-patients, out-patients
  and drug store facilities at the district
  hospital were also renovated as appropriate.

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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.

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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.

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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.

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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 RDF
• Cost per drug item KShs 20 SP costs KShs 4 per
  tab KShs 12
• Complete treatment KShs 40 Paracetamol costs
  KShs 10 for 18
• tabs
• Total px cost KShs 40 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

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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.

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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