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Community Based Approaches to Reduce Medication Stockouts: Kenya

 

Author(s): Sonak Pastakia1, Imran Manji1, Beatrice Jakait1
Affiliation(s): 1USAID-AMPATH Partnership, Eldoret, Kenya
1st country of focus: Kenya
Relevant to the conference theme: Medicines and diagnostics
Summary: Over the last ten years, AMPATH has successfully scaled HIV care across Western Kenya, establishing a network of over 27 health centers and treating over 140,000 HIV-positive patients with 45,000 currently receiving anti-retroviral therapy.  As AMPATH continues to expand its mission to address additional conditions beyond HIV, there is an enormous challenge of addressing the large needs for medical supplies and medications beyond HIV.  To address this need, AMPATH has partnered with the community and ministry of health facilities to develop sustainable solutions to reduce stock outs and facilitate care for the multifaceted array of conditions patients face in resource-constrained settings.
What challenges does your project address and why is it of importance?: The most daunting obstacle AMPATH faces to reach our goal of addressing additional disease states is the severe limitation of available drugs within the MOH supply chain.  Most MOH facilities face significant stock outs of key medications, with essential drugs frequently unavailable to patients.  This forces patients to seek out medicines in the commercial sector where prices can be ten times as high and drugs are often of substandard quality (Estimates from the WHO suggest 30% of the drugs available on the market in Western Kenya are fake or substandard).  Most patients are unable to pay commercial prices and therefore go without needed medicines, or can only afford a portion of their prescription and are undertreated. The poor supply of medicines is especially concerning given that current levels of drug demand are very low, both because efficient diagnosis and appropriate prescription of medicines is low and because patients who know that medicines will not be available are less likely to show up to health facilities.  Without access to medicines and supplies, all of AMPATH efforts to expand beyond HIV will come to a grinding halt.
How have you addressed these challenges? Do you see a solution?: In order to ensure reliable and affordable access to medicines, AMPATH will partner with the MOH (Ministry of Health), MOH facilities, and each community to implement Community Revolving Fund Pharmacies (CRFP) at each health facility.  These pharmacies will act as a back-up and will provide patients medicines only when there are stock-outs at the MOH pharmacy.• Distinct: The operation of the CRFP will be distinct from the MOH pharmacy or the dispensing of anti-retroviral drugs from the AMPATH pharmacy to ensure separation of stocks, records, and cash.• Dispensing: CRFP will only dispense drugs when those drugs are stocked out at the MOH pharmacy.  Patients will therefore first go to the MOH pharmacy to have their prescription filled, and only proceed to the CRFP for medicines that are out of stock.  • Pricing: To encourage use of the MOH pharmacy and to ensure sustainability of the CRFP, pricing for drugs will be slightly higher than government co-pays, about 5-10% in most cases.• Fee Waivers: Fee waivers will be granted to indigent patients based on set criteria and processes that will be developed with MOH and community leadership.  • Staffing: The CRFP will be staffed with existing MOH staff who will be responsible for day-to-day operations.  AMPATH staff will support staff in implementation and management, but MOH staff will be responsible for the success of the CRFP.• Governance: The CRFP will be a non-profit entity and governed by a Management Committee made up of representatives from MOH, AMPATH, and the community.  A signature from each of the three partners will be required for any cash disbursements.• Cash Management: A separate bank account will be set up for the CRFP with regular deposits of co-pays.  Any disbursements will require co-signatures and will only be used for drug re-purchases, transport money for bank deposits, and printing and stationary costs for the CRFP.  • Drug Procurement: MOH health facilities do not have a drug procurement pathway except through their normal drug supply chain, which does not have flexibility for additional orders.  AMPATH will therefore facilitate drug procurement to ensure efficient drug re-supply and access to good drug tender prices.  • Accountability: Rigorous records will be kept for CRFPs to ensure that its purpose is achieved and to avoid mismanagement.  Drug inventory and dispensing, cash transactions and totals, and the number of fee waivers and drug stock-outs will be carefully tracked for each CRFP.
How do you know whether you have made a difference?: We have piloted this concept at three sites and have been frequently monitoring and auditing our program to track all aspects of this program.  Preliminary data from our first site reveals the following:• Demand: Patient demand has been high revealing the need for the Revolving Pharmacy.  Over 900 prescriptions were filled over seven weeks, averaging about 130 per week.• Inventory Management: Inventory management has been reliable with a low margin of error (average of 1.5% difference between recorded inventory and actual count on May 23, 2011).• Financial Management: Financial management has been strong with the Total Co-Pays Expected from drugs dispensed matching the Total Amount Collected in the bank account with neglible differences(Co-Pays Expected = KES 49,272; Total Amount Collected = KES 49,960).• Sustainability: The first seven weeks have yielded KES 16,622 in profits, about KES 2,375 per week.  This is a good margin for sustainability, but it is too early to estimate the average drug demand given erratic MOH drug supply.  However, there is a positive margin for all drugs, meaning that patient co-pay per unit is greater than the procurement cost per unit• Drug Stock-outs: Drug stockouts have been reduced considerably as the baseline evaluation of the clinic revealed the clinic typically averaged only 60% availability of the necessary medications.  Preliminary data reveals that availability of supplies improved to 87%.  While this availability must improve to be closer to 100%, we have already made considerable strides in alleviating stockouts.• Fee Waivers: There was only one fee waiver recorded for the first seven weeks and guidelines and processes for fee waivers are currently being revised to improve this process.
Have you or the project mobilized others and if so, who, why and how?: Through regularly scheduled meetings with the various stakeholders in this pilot project, the community’s receptiveness to this program has been incredibly positive and encouraging.  Because of the marked success of our model, other sites within our catchment area have been repeatedly requesting that we initiate more of these programs.  Through our deliberate efforts to sensitize and mobilize the community to access these services, we have engendered a sense of ownership that has enabled us to ensure long term support for this program.  Since the implementation of the initial pilot, we have been able to establish two additional pharmacies that have improved supply availability throughout our catchment area.  Furthermore, these pharmacies have enabled us to establish new chronic disease management and primary health care services at sites that did not previously exist.
When your donor funding runs out how will your idea continue to live?: The CRFP model was designed to be self-sustaining.  By charging affordable co-pays to patients and managing drug procurement through a tender process that can access low-cost medicines, continued donor support will not be needed after peak demand has been reached.  Such a model is critical to the success of Primary Health Care and Chronic Disease Management efforts because of the unreliability of MOH drug supply and the unaffordable prices that commercial pharmacies charge.  From the early data from our first pilot site it is clear that the pharmacies are capable of generating profits beyond the initial investment made by donors to start up this program. CRFPs will stock 86 medicines that have been identified as essential and likely to stock-out at MOH pharmacies.  All medicines have lower procurement costs per unit than patient co-pay costs per unit.  While fee waivers for needy patients are an uncertainty, there should be enough margin on the majority of drugs dispensed to cover for patients who cannot pay.  This will be monitored carefully during the pilot period and utilized for patients who absolutely cannot afford the medication costs.  Furthermore, all profits will be reinvested within the program to start additional pharmacies within our catchment area.  If government supply chain improves and obviates the need for these community pharmacies, the money will be reinvested into different aspects of the program.  The success of this program will enable AMPATH to continue expanding access to care beyond HIV throughout its vast catchment area which serves over 2.2 million people.

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