In Uganda, like in most parts of Africa, many people living with HIV and AIDS are responding well to antiretroviral therapy (ART). 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 go to their health centre, sometimes traveling far by foot or bicycle, waiting for hours in a crowded clinic to see an overburdened health care worker, and then standing in line at a dispensary to pick up their supply of antiretroviral (ARV) therapy. It’s disruptive to normal life; inconvenient, not particularly private, and takes time and money if they must pay for transportation or possibly lost wages if they take time away from their work.
In the line of patients queuing at the antiretroviral treatment (ART) clinic at Kiboga Hospital, in the Buganda Region, are many people who have travelled far by foot, on bicycles or via public transport. Many have incurred travel costs and a loss of income due to taking a day’s leave to come to the facility to get their lifesaving medication. Most of the people in this queue, along with thousands of other stable people living with HIV in Uganda, will soon be able to access their antiretrovirals (ARVs) more conveniently.
Volunteers are engaging with queuing patients to introduce them to a new system Uganda’s Ministry of Health is piloting in their area. This new system will allow patients to collect their medications from one of several retail pharmacies closer to where they live or work. And pick up chronic prescriptions within more flexible hours than the clinic can offer. Almost 10% of the people at the clinic sign up for the programme on the spot.
An organisation called Africa Resource Centre (ARC) has been working with Uganda’s Ministry of Health to develop and roll out a decentralised drug distribution channel pilot for stable people living with HIV. This drug distribution channel will help reduce the cost and time burden on patients, free up healthcare worker capacity at regional healthcare centres, and increase adherence to ART regimens by making medication more accessible.
Shaking up the supply chain
In Uganda, as in much of Africa, the distribution of ARV medicines and other priority lifesaving chronic products has typically been provided free to patients and accessed at public sector health clinics and hospitals. These clinics receive the products through supply chains commonly operated and regulated by government agencies. In urban areas, retail outlets are often more conveniently located for patients and much less crowded. Still, until now, there was little incentive for private retail pharmacies to provide ARV and chronic medicines.
ARC did extensive work to understand the geographic distribution of people living with HIV in Uganda and mapped the locations of retail pharmacies in urban areas. For urban patients, it became clear that providing more convenient access to medication could be achieved by the government partnering with commercial pharmacies to provide this service.
Additionally, ARC developed an investment case which showed that the cost of incentivising pharmacies to be part of the programme – while still providing the service free to patients – would save thousands of nursing hours for the Ministry of Health. It would also eliminate the need for the government to make significant infrastructure investments to supply the medication directly.
Of course, introducing this level of innovation to an existing healthcare system requires a considerable investment of time to communicate the value and practicalities to the pharmacies and patients interested in using the model. ARC and teams from the Ministry of Health are spending ample time during the pilot phase doing support supervision visits and listening to feedback.
One of the hospitals that is part of the pilot phase of the drug distribution model, Mubende Regional Referral Hospital in Central Uganda, has over 1 200 patients signed up to collect this model. Healthcare workers at the hospital report that their patients who have signed up for the model like it and want to continue using it.
Another patient who eagerly signed up for the programme is a schoolteacher from one of the pilot districts. Peter Masiko* had previously faced the risk of losing his job because once every few months, he wouldn’t show up for work. He had to go and collect his medication from a government healthcare facility. Still, Masiko didn’t want to explain his absence to his colleagues as he was afraid of the stigma associated with disclosing his HIV status. Since joining the retail pharmacy pilot, Masiko now takes just 15 minutes during his lunchtime to visit a nearby pharmacy and collect his medication.
The level of interest and excitement about what the retail pharmacy model can offer patients, and the improvements it will bring to the healthcare system in terms of capacity, make it a valuable, transformational change for Uganda’s health landscape. This distribution model is the first such health supply chain initiative of its kind in the country, especially at this scale. To date, around 18 000 people have signed up to be part of the programme, and ARC’s goal is to have at least 150 000 people using it by the end of 2022.
Uganda’s journey with an alternative drug distribution model for chronic patients is just beginning. As the project rolls out in more regions, the vision is for health facilities to be less congested, and medicines available more conveniently for all who need them. It’s ambitious, but the Ministry of Health is demonstrating the kind of commitment and leadership that are essential for systematic change.
* Name changed to protect his identity.