ARTICLE

NEW DISTRIBUTION APPROACH FOR LIFESAVING MEDICINES IN UGANDA

ARC HAS RECRUITED A SUPPLY CHAIN EXPERT TO WORK WITH THE MINISTRY OF HEALTH IN DESIGNING ITS OWN MULTI-CHANNEL DISTRIBUTION SYSTEM FOR MEDICINES.

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BACKGROUND

In Uganda, like in most parts of Africa, many people living with HIV and AIDS are responding well to antiretroviral therapy (ART)[1][2]. Their health is increasingly stable, and they are getting on with their lives; attending school or working to support their families. But every three months, patients on ART need to visit a health facility, sometimes travelling far on foot or by bicycle, waiting for hours to see an overburdened healthcare worker, and then standing in line at a dispensary to pick up their medicines. This is not only inconvenient—it takes time and money if they must pay for transportation or lost wages if they take time away from their work. It also contributes to congestion at crowded clinics.

Throughout Africa, the distribution of lifesaving medicines, vaccines and health products is typically provided free to the patient from public sector health clinics. These clinics receive the products through supply chains commonly operated and regulated by government agencies. There is little incentive for private retail pharmacies to provide them, even though retail outlets are often more conveniently located for patients—at least in urban areas—and much less crowded.

APPLYING PUBLIC HEALTH SUPPLY CHAIN LESSONS FROM SOUTH AFRICA INTO

UGANDA

Taking note of the success South Africa has had in scaling innovative medicine distribution systems to improve patient access to medicines and decongest health facilities[3], Uganda has taken this approach and adapted it for its local context. One of the ways South Africa’s National Department of Health (NDoH) is tackling the challenge of getting medicines to so many patients with chronic illnesses is through its innovative Central Chronic Medicine Dispensing and Distribution (CCMDD) Programme[4]. The CCMDD centralises both the dispensing of medicines and their distribution to a designated and convenient pick-up point that each enrolled patient selects. The pick-up point might be a cooperating retail pharmacy, a private clinic, a nongovernmental organisation, or a community-based organisation like a church.

First piloted in 2014 in 10 districts, the CCMDD had enrolled nearly 2.2 million patients by March 2018. These patients collect their medicines from 2,030 pick-up points in both urban and rural areas.

In 2017, a business case for the continued scale-up of the CCMDD Programme[5] found that in 2017 the programme resulted in a:

  • 48% decrease of NDoH’s cost of treating chronic patients
  • 67% decrease of patient cost for collecting medicines
  • 22% increase in patient adherence

The CCMDD Programme grew out of an idea first conceived in 2004 by a TB patient, Neo Hutiri. “During my treatment, my biggest challenge was the long waiting times at the clinic, I was losing over three hours in long queues with every visit. Most of the other patients that waited along with me had to miss work just to collect their medicine[6].” As an automation engineer, Hutiri knew there had to be a better way, and he founded a company that developed the Pelebox Smart Locker[7], a digital dispenser that is installed in health facilities, where patients with chronic illnesses can conveniently pick up their medicines. The CCMDD is expanding on Hutiri’s model to include many other pick-up points and a central distributor—Pharmacy Direct—that has national reach. The entire approach is based on multi-channel distribution, commonly used for fast-moving consumer products and beverages.

At a knowledge sharing conference on differentiated service delivery[8] for HIV in 2018, representatives of Uganda’s Ministry of Health (MoH) and AIDS Control Programme attended a presentation of the CCMDD business case. The clear benefits of alternative distribution channels—also known as a differentiated service delivery model (DSDM)—appealed to the Ugandan delegation. They decided to pursue the idea in a way that worked within their local context, collaborating with the National Drug Authority (NDA) and the Pharmaceutical Society of Uganda (PSU) to revise policies and regulations that might hinder a DSDM approach. During the conference, they connected with representatives from ARC, which had helped the South Africa NDoH to document the CCMDD business case. The ministry was clear about its needs, open to new ideas, and engaged ARC because of its growing reputation as a trusted advisor and its commitment to long-term transformation.

COLLABORATION TO DELIVER A CUSTOMISED AND CONTEXT-SPECIFIC SOLUTION

During a scoping mission in Uganda, the ARC team learned from the US PEPFAR agencies (Centers for Disease Control and Prevention (CDC) and United States Agency for International Development (USAID)) that several DSDMs were already being piloted, including the use of urban and peri-urban retail pharmacies in and around Kampala as pick-up points[9].

The IDI-KCCA Community Pharmacy ART Refill Programme was conceived and piloted in 2016 by Makerere University’s Infectious Diseases Institute in collaboration with the Kampala Capital City Authority. It offers stable patients on ART and/or TB medicines a convenient place to pick up their medicines that doesn’t involve a trip to the health clinic and long waits at the dispensary.

In partnership with the US CDC, the Infectious Disease Institute obtained authorisation from the MoH, the NDA and support from PSU to operate the initiative. The exploratory work undertaken by ARC found support from all stakeholders in rolling out the initiative, and by mid-2019, the Differentiated Service Delivery Technical Working Group (which includes the Global Fund to Fight AIDS, Tuberculosis and Malaria, USAID, CDC and a range of implementing partners) endorsed the scale-up of the model across Uganda.

The MoH and NDA committed to address any legal and regulatory changes required to underpin this new service. The PSU began exploring an engagement framework with the MoH to create the policies needed to enable private pharmacists to participate in the continuum of care for stable patients on ART, and for placing government-owned products in private pharmacies. ARC was assigned the task of helping to design an efficient supply chain for antiretroviral and TB medicines from the National Medical Stores to the participating retail pharmacies.

DEVELOPING AN EFFECTIVE AND SUSTAINABLE DSDM

For the DSDM to work in any country, including Uganda, there must be good data, secure locations for the medicines, and an emphasis on patient privacy as part of normal practice and due to stigma. With that in mind, a DSDM built around retail pharmacies would seem to be part of the solution. However, it cannot be a one-size-fits-all model because roughly 80% of Ugandans live in rural areas, while most retail pharmacies are located in urban areas. Meeting the needs of rural residents involves overcoming the lack of real-time information, challenging last mile logistics, and addressing the absence of private sector outlets. It also requires safeguards for regulatory compliance on pharmaceutical control at informal pick-up points.

Current regulations stipulate that prescription medicines can only be managed within an accredited pharmacy, but there are over 1,000 over-the-counter drug shops accredited by the NDA that, with the right oversight and regulatory changes, might offer opportunities.

ARC has placed an expert with deep commercial sector experience in multi-channel distribution and in human resources to work within the MoH. He is co-leading the DSDM project, working with and building the capacity of a government-appointed project lead and other counterparts. As of mid-2019, two workstreams are underway:

  • Mapping and geocoding facilities, which provides the DSDM team with detailed information about the health facility network, including pharmacies and drug shops, and demand for ART services. Not only will this information help guide the design of the DSDM, it also builds MoH capacity to collect and keep the data up to date and apply a commercial route-to-market approach.
  • Fact finding about supply chain channels, particularly in the private-for-profit and private not-for-profit sectors. This will include what the data management systems are, and how ART products are delivered across all sectors. The team will identify different modes of distribution, gaps in distribution, and opportunities for new routes to market—delivering to the last mile—based on prevalence rates and patient concentrations.

 

Uganda’s journey with DSDM is only just beginning. Its vision of success is that, in three years, health facilities will be less congested, and medicines will be available and more convenient for all who need them. It’s ambitious, but the MoH is demonstrating the kind of commitment and leadership that are essential to systematic change.

ARC is dedicated to being the independent advisor that can help ministries of health to align and coordinate with donors, development partners, and the private sector to achieve this vision.

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[1] Differentiated Service Delivery. Summary of published evidence, Facility-based individual. http://www.differentiatedcare.org/Resources/Summary-of-published-evidence/Facility-based-individual

[2] Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach–2nd. ed. pp240. WHO. 2016

[3] Magadzire et al. 2016. Novel models to improve access to medicines for chronic diseases in South Africa: an analysis of stakeholder perspectives on community-based distribution models. Journal of Pharmaceutical Policy and Practice (2016) 9:28

[4] Health Systems Trust. 2019. The CCMDD Story.

[5] Ibid.

[6] https://www.pelebox.com/story.html

[7] https://qz.com/africa/1636120/south-african-inventor-wins-engineering-prize-for-drug-dispenser/

[8] http://www.differentiatedcare.org/Models/TreatmenT

[9] https://theacademy.co.ug/wp-content/uploads/2019/04/Outreach-at-IDI-Joanita-Kigozi.pdf