The most often attributed causes for a stock out in a public health center in Uganda are inefficiencies within the central warehouse system. For example, long lead times and under deliveries. While this may be true sometimes, it is hardly the primary problem in the supply of essential commodities. Here’s why.
I have recently had the opportunity to explore bottlenecks in the supply of essential commodities in the public sector and three main gaps have come up as the underlying challenges to their supply: Quantification, Process and, fundamentally, Funding.
World Health Organization defines essential medicines as drugs that satisfy the health care needs of the majority of the population. They should be available at all times, in adequate amounts and in appropriate dosage forms, and at a price the community can afford. In Uganda’s context, think of Paracetamol or an antibiotic like amoxicillin.
All public health centers (HCs) in the country are supplied by one warehouse, National Medical Stores. Higher HCs, ie Hospitals and HCIVs, are under a pull system. This basically means that these HCs can make an order for commodities they need, under a specific budget, which are delivered on a bimonthly basis by NMS. The HCIIs and HCIIIs on the other hand are under what is termed as an Informed Push system (almost a pull approach). These lower level HCs quantify their needs only once every year in a process known as the Essential Medicines Kit revision. This is also under a specified budget per HC but customized per district on the same bimonthly delivery schedule. As a result, all HCIIIs in a district receive a fixed set of commodities in every delivery throughout the year, regardless of variations in patient volumes. The same applies for HC IIs, with a slightly different set of commodities. The VHT supply structure has been run by Ministry of Health partners and thus has been independent of either of these two systems. Nonetheless, work is in progress to integrate it into the NMS supply chain.
These supply systems demonstrate the need for proper quantification, an efficient coordination process and a sufficient budget for commodities. However, the current situation shows a lack of stock data visibility at district and central level to accurately inform EM kit revision processes and procurement planning. Additionally, the variations in disease patterns across the year as well as patient loads require revision of the kit on a more than once a year basis to meet the need during peak disease seasons. The Essential medicines ordering process for higher level centers is often based on estimates as opposed to use of stock card data.
Funding nonetheless is the biggest bottleneck to supply. Health centers have made some strides in improving the availability of commodities by ordering in time and quantifying based on estimated need. This is shown by the improved availability of free commodities like Antiretroviral drugs. Essential commodities continue to struggle because of the budgetary ceiling per health facility regardless of the level. Each facility is credited for 95% of the commodities every delivery. This ceiling is not sufficient to complete patient doses for most maternal and childhood illnesses for HCs that see over 2000 patients in a month. This hinders the availability of commodities at both higher and lower levels since NMS only delivers against the budget per delivery and the mandate of budgetary adjustment remains with the Ministry.
With this in mind, it’s clear that there are more factors at play in the supply of essential commodities. However, unless efforts are geared towards addressing the budgetary limitations, stock outs will continue to affect commodity availability.