from EVIDENCE to POLICY Learning what works, from the Human Development Network April 2013 (Update) 76881 The Challenge of Ensuring Adequate Stocks of Essential Drugs in Rural Health Clinics Health experts and policymakers want people to have Zambia, the World Bank supported a project explor- access to affordable and high-quality medical care. But ing how to guarantee the availability of essential medi- in some developing countries, making quality health- cines in often-remote health facilities. The 12-month care available may first necessitate ensuring that essen- study, which covered almost 22 percent of Zambia’s tial medicines are available, such as anti-malaria pills rural population, found that streamlining the delivery and antibiotics. The challenge of guaranteeing a steady of medicines directly to health centers and introducing supply is not only related to the financial side of paying a dedicated staff member to help facilitate and track for medicines. Poor roads, limited communications and orders cut down on the rate at which clinics ran out HEALTH storage problems can make it difficult to keep medical of basic medicines. Based on the results, clinics in facilities stocked with what they need to provide chil- districts that were part of the pilot study are now dren and adults with regular and lifesaving care. able to order drugs directly from a central phar- The World Bank is working to help countries pro- macy. Donors and the Government of Zambia are vide quality medical care, a key part of many of the working together to expand the program to the rest United Nations Millennium Development Goals. In of the country. Case Study Zambia Zambian officials were frustrated by shortages of es- dren and adults at greater risk of illness or death. The sential medicines in public health facilities in rural and problem was not the availability of the necessary drugs semi-rural parts of the country. Clinics frequently re- in the country overall. It was the distribution system. ported that they had run out of basic lifesaving drugs, While the government had a working system for such as antibiotics and anti-malarial drugs, leaving chil- moving medical supplies from the capital Lusaka to district stores and hospitals, it was less efficient at get- Did You Know… ting supplies from district stores to local health facilities. Life expectancy in Zambia is 45 years. District Health Management Teams, which reported to And the under-5 mortality rate is 141 per 1,000… the Ministry of Health, were responsible for sending Compared with an average of 129 for sub-Saharan Africa. supplies from the district stores to some 1,500 health facilities. Reaching the facilities could be challenging. The facilities were spread out and some roads required In Model B, health facilities submitted orders special, off-road vehicles. Communications between the directly to the central Medical Stores Limited. The facilities and the district stores were intermittent—usu- district store, instead of stocking drugs, acted as a ally via two-way radio. Local facilities were running out point of transit, receiving and forwarding-on already of medicines at a rate that was double or more that re- packaged orders with the help of a new commodity ported by district stores, a clear sign that drugs were not planner. The planner worked with health facilities getting to where they were needed. to make sure they got their orders in properly to A pilot program, consisting of two different models the central stores and also delivered the packages as for distribution, was initiated to test the best way to over- they arrived. come the bottleneck at the district level. In Model A, a The pilot began in April 2009 and ran for 12 commodity planner was put in place at the district level. months. The two models were each implemented The person was responsible for making certain that health in eight rural and semi-rural districts, randomly se- clinics submitted accurate monthly orders to the district lected out of a total of 50 possible districts. An addi- store, for collating the clinic orders, and then placing the tional eight districts were selected for observation as bulk order with the central medical stores with the na- controls. A baseline survey was conducted prior to tional stock of drugs, called Medical Stores Limited. The the start of the pilot, and then again at the end. In- goal was to ensure that the district stockroom had a ready formation was collected on the inventory and stock- supply of items for the clinics. The planner would put out rates of 15 drugs, in addition to interviews with together packages for the clinics and arrange transport. the community planners. HEALTH Findings Hiring a special facilitator to work directly Life-saving malarial drugs were among those with health facilities, while minimizing more likely to be in stock, especially in health the role of district stores for storing and facililties that directly ordered their own delivering medicines, helped clinics stay supplies from the central stores. better stocked. Health facilities that had more control over ordered medi- In Model A, which introduced a commodity planner to cal supplies were better able to maintain needed supplies of coordinate orders, the stock-out rates for needed drugs essential drugs. At the end of the 12-month pilot, malaria ranged from 17 percent to 46 percent after one year, treatments for adults were out-of-stock in 6 percent of fa- depending on the particular drug, compared with the cilities, while pediatric treatment was out of stock in 12 per- baseline rate ranging from 34 percent to 74 percent. In cent. This compared with a previous rate of 48 percent for Model B, in which the role of the district office was fur- adult treatments and 43 percent for pediatric treatment. In ther minimized, the out-of-stock rate for drugs ranged facilities that relied on the regular system, but now had a from 1 percent to 33 percent, compared with a baseline commodity planner to help coordinate orders, the stock- rate of 40 percent to 72 percent. out rate for adult malaria treatment was 22 percent (com- pared with 43 percent before the study) and for pediatric treatments, 30 percent, down from 34 percent. This bulletin summarizes the results of the research paper “Enhancing Public Supply Chain Management in Zambia� by Monique Vledder, Jed Friedman, Mirja Sjoblom and Prashant Yadav. The paper is based on the results of the World Bank-supported Essential Drug Public Pilot Program in Zambia, which was funded by the World Bank, U.S. Government and DFiD. When looking at the number of days that Researchers estimated that if Model B were essential drugs were unavailable, health implemented nationwide, malaria-related facilities in Model A did only marginally bet- deaths could drop by more than 20 percent. ter than the control group. In children under the age of five, the number of Pediatric malaria drugs, for example, were out of stock an deaths annually from malaria may decline to an es- average of 29 days, out of a maximum of 92 days, in the timated 12,218, from an estimated 15,538 current- control facilities. For facilities in Model A, the stock-out ly. In the over-five age group, deaths from malaria duration averaged 18 days; in districts in Model B, the would drop to 1,318 from 1,766 annually. This is a average number of days this essential medication was out result solely due to the increased availability of life- of stock dropped to five days. saving drugs at the clinic. Introducing a commodity planner into the system helped facilities better coordinate their orders with the central agency. The rates at which health facilities placed regular orders with the central agency, a key part of ensuring the avail- ability of drugs at the district level, rose to 95 percent or better. This compared with a pre-pilot rate of 72 percent to 79 percent, depending on the district. “The program has worked very well. Now people have access to medicines. Despite the hardships, I would consider continuing as a commodity planner,� another planner concluded. Nonetheless, commodity planners still faced And when essential drugs are available, some of the same transportation, storage and households are less likely to lose income communications problems that district stores because a working adult is ill or has to stop faced in getting medicines to remote clinics. working to care for an ill child. Commodity planners had to rely on vehicles and fuel Researchers estimated that if Model B were applied provided by the district health office to get the sup- throughout Zambia, more than $1.6 million annually plies to the clinics. This meant they were “competing� in expected household income loss would be avoided. with other programs for use of vehicles. They also did In turn, this means that families would be less likely to not always have sufficient storage space for medicines shipped in from the central agency. Communicating The Zambia National Malaria Indicator Survey (2008) reported with the facilities was another problem. Most health that just seven percent of children in rural areas under the age facilities have to rely on two-way radio, which made it of five received pediatric ACT (Artemisinin-Based Combination Therapy)—the most effective first-line medicine for malaria— difficult for community planners to be in contact on a within 24 hours of starting a fever. regular basis. have to sell assets, pull children out of school or lose Model B cost an additional $3,971 per district per month, crops because of the often-devastating economic-related while Model A, which was not as effective, cost $3,479. effects of severe illness. More than half went for the commodity planner’s salary, with the remainder covering expenses associated with The cost of taking steps to boost the availability staff-related expenses, office supplies and training. When of essential drugs in rural clinics is not weighed against stock out rates, Model B is almost four cheap. But it is still worthwhile. times more cost-effective than Model A. Conclusion Making policy from evidence The pilot underscores that successful distribution of to look at what happens after that. Are people able to drugs is about more than just money—or having the access what they need? Is the quality of care, in other right amount of stocks available in central locations. words, on par with the new-level of available drugs? Ensuring that medicines get to clinics is critical for a These are questions that policy makers and health ex- functioning health system. Future research may want perts need to also consider. The Human Development Network, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Department for International Development. THE WORLD BANK, HUMAN DEVELOPMENT NETWORK 1818 H STREET, NW WASHINGTON, DC 20433 Produced by Office of the Chief Economist, Human Development Network, Communications/Aliza Marcus amarcus@worldbank.org First issued November 2010/Updated April 2013