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Stock-outs launch presentation - 190514
1. More money alone will not help
stock outs
Twaweza & Overseas Development Institute
2. Stock-outs problem is well
acknowledged…
• MOHSW Mid-term Review of the Health
Sector Strategic Plan III (2009-2015): “the
general picture indicates continued low
availability of essential medicines, with no
clear trend towards improvement over the
past few years”
…In spite substantial reforms & high-level
commitments
3. Key questions of the study
1. Why are there persistent drug stock outs and
under provision of essential medicines in
health facilities, despite on-going reform
efforts?
2. What can be done to address the problem,
particularly for civil society or demand-side
initiatives?
4. The Political Economy Approach
• In-depth analysis of the various factors that
influence the behaviors and incentives of key
individuals and institutions involved at
different stages in the supply chain
• Focus on issues of governance, transparency
and accountability
• Not looking at technical components of the
medical supply chain
5. Methodology
• Step 1: Identify the problem (key questions)
• Step 2: Map features (political, economic,
demographic, etc.) most relevant to stock-
outs; literature review
• Step 3: Identify & interview stakeholders
– 87 open-ended interviews at central level and in 4
districts
• Step 4: Distil key issues, and suggest a range of
practical strategies
6. Findings: Five key reasons stock-outs
persist
1. Political incentives – visible reform efforts &
quick results are preferred by politicians (and
voters)
– “A dispensary in every village, a health centre in
every ward and a hospital in every district”
7. Findings: Five key reasons stock-outs
persist
2. Resource shortages – financial, human – are
real, though more funding will not solve
problems of transparency & coordination
– Budget for medicines & supplies: TZS 80 billion
vs. estimated need of TZS 198 billion
– On the other hand: no transparency on MSD
cash flows & amount of working capital
– MSD system & facilities in an “opaque cycle”
8. Findings: Five key reasons stock-outs
persist
3. Data on medicine orders, deliveries and
consumption are unreliable, not widely
accessible, and under-used
– MSD inaccurate forecasting
– Few facilities keep good patient records
– “General culture where data and information are
something that needs to be collated and passed
on, rather than utilized”
– Medicines prone to stock-outs are pricey and
fast-moving
9. Findings: Five key reasons stock-outs
persist
4. Poor oversight & unclear accountability –
unclear mandates & reporting lines, particularly
at district level, contribute to potential leakages
of drugs
– Shifting the responsibility: central level blames down
the chain; local-level blames up
– Culture of not reporting: civil servant jobs are kept
regardless of performance
– 3 overlapping sets of actors at district health
administration: elected representatives, civil service
officials, and central government representatives
10. Findings: Five key reasons stock-outs
persist
5. Citizens’ voices & influence remain low, even
though citizens are aware of stock-outs and
perceive it as a problem
– Public expectations are around “visible” resources
(ambulances, construction),
– Political engagement tends to be personalized and
reactive – e.g., purchasing medicines for individual
constituents
– Health facility committees lack information and
cannot challenge the system
11. …and yet there are positive examples
• Research also found instances of pro-active
government and civil society
– Iramba’s improved monitoring by DMO
– Wajibika’s “satellite” approach
– PADI’s community score-cards
12. Four Ideas for Collaboration
1. Independent verification of facility-level data
2. Greater transparency of data at facility level
3. Fostering positive deviance
4. Public dialogue & greater engagement
→ A coalition for getting things done ←
Hinweis der Redaktion
CAN ALSO MENTION
Ifakara Health Institute (2012): 37% of public health facilities have proper stock of essential medicines
REPOA (2012): 88% Tanzanians experienced stock-outs in the health centers in the previous year
TZ Open Government Partnership (OGP): 2nd commitment reads: Posting orders and receipts of medical supplies from MSD online and on notice boards to the facility level and updated in real time
INTERVIEWS AMONG:
Institutions at the central level (MOHSW, MSD, donor agencies, and civil society groups)
Interviews with government officials, MSD staff, members of health committees, health workers and clients of health facilities in Iringa, Mbeya, Songea, and Mbinga districts.
Source: MOHSW (2006): “Primary Health Services Development Programme 2007-2017” (PHSPD/MMAM)
This pledge would require establishing & staffing additional 5,162 dispensaries, 2,074 health centers, and 8 district hospitals
… it would nearly double the total number of public health facilities & staff
Source on budget for medicines & medical supplies for 2012-13: MoHSW mid-term review 2013
Opaque cycle:
Facilities required to submit all drug orders first to MSD
Can only purchase from alternate/private suppliers once MDS confirms stock-out, which can take a long time
Can only purchase from alternate/private suppliers using facility-generated funds (e.g., user fees) which are typically limited
Facilities sometimes order meds according to what MSD has in stock rather than according to needs, and stockpile items in anticipation of future stock-outs
A note on human resources: shortages in HR especially severe in the pharmaceutical sector; only 60% of district pharmacists have pharmacy training (USAID, 2011).
MSD forecasting based on historical sales, which are inaccurate as they exclude any stock-outs
There are efforts to improve data management – e.g., Health Management Information Systems (HMIS) and SMS 4 Life – which have improved data collection, but there hasn’t been use of the data or action on basis of what data reveals
e-LMIS system (ILS Gateway) has greatly restricted access, no guidelines on data sharing
Quote on “general culture…” from USAID (2011 report)
Which meds are stocked out: Those that are easy to sell on the street or to private pharmacies -- especially antibiotics. Cheaper meds, and more specialized meds experience stock-outs much less.
Quote from Dar: “If you asked me where are the leakages, I’d put my money on the medicines getting to facilities and disappearing from there.”
There have been cases of shutting down private pharmacies for stocking government drugs – examples from Songea & Mbinga (but could not trace the supplier). Also the publicized case in Mwanza region, where in Sept 2013, 120 pharmacies were closed for illegally selling government medicines.
Citizen awareness of stock-outs: Twaweza Sauti za Wananchi study (Sept. 2013): 41% of Tanzanians unable to access medicine needed in the government facility
Why would citizens “prefer” more visible resources – partly because med stock-outs is a more complex issue.
Citizens may not consider stock-outs a major issue until meds are needed (when one is ill) – and in cases of need, it’s easier to purchase them from a private pharmacy than demand the right for medicine from public facilities.
Also, patients/clients often demand medicines, even when not warranted. Over-prescription of meds has been documented in several studies.
There are some examples of action from the local government & the public:
Iramba experience (active DMO….); plus two other examples of RMOs who had initiated their own investigations into stock-outs
Wajibika: health centres are hubs for monitoring dispensaries in their area
Community score-card program in Songea (implemented by PADI), for better accessibility of drugs to elderly
