By Dr. Elizabeth Ominde-Ogaja, Dr. Gunter Boussery and Dr. George Otieno

1. Improving Access to Essential Medicines in Kenya: The Nyamira District Revolving Drug Fund Experience: By Dr. Elizabeth Ominde-Ogaja, Dr. Gunter Boussery and Dr. George Otieno

2. Abstract • Introduction: The availability and accessibility of good quality essential drugs has been a challenge for the Ministry of Health in Kenya since the attainment of independence in 1963. The problem was particularly acute at the rural health facility level. Attempts to address the issue resulted in the introduction of the kit-system in the early 1980s, followed by cost-sharing around 1989. Despite these measures there were still numerous reports of stock-outs at various public health institutions around the country. • In June 1994, the Ministry of Health sent a proposal to the Belgian Administration for Development Cooperation requesting for assistance with the establishment of a Revolving Drug Fund (RDF) to be piloted in Western Kenya. The main goal of the project was to “develop a new institutional framework within which an improved drug supply system can be effected”. Further consultations resulted in the selection of Nyamira District in Nyanza Province (Western Kenya). • Objectives: Three strategies were used in achieving the project goals: • The. To establish an independent self-financing RDF through the development of a new institutional framework. • The development of improved financial and drug management systems focusing on the following areas: • Drug selection • Procurement • Storage and stock control • Distribution and • Accounting • To monitor the Rational Use of Drugs • Methods: • The RDF was set up through the establishment of organizational structures, community mobilization, building of the District Medical Stores coupled with renovation of facility stores, the Improvement of Logistics support, capacity building of health workers at the RDF and in the health facilities, selection, procurement and distribution of drugs and installation of an efficient management system • Results: An efficient RDF was established which was able to secure the regular supply of drugs for 24 month period a 24 month period

3. Introduction: • The availability and accessibility of good quality essential drugs has been a challenge for the Ministry of Health in Kenya since the attainment of independence in 1963. The problem was particularly acute at the rural health facility level. Attempts to address the issue resulted in the introduction of the kit-system in the early 1980s, followed by cost-sharing around 1989. Despite these measures there were still numerous reports of stock-outs at various public health institutions around the country. • The cost-sharing system was not a full cost-recovery scheme as the fee levied on each item was applied in an arbitrary manner. Even with the cost-sharing initiative the drug supply to the health facilities left a lot to be desired. The hospital management committees were constantly looking for new ways to boost revenue to finance drug supply and facility improvement. • There was no harmonization of these approaches across the country. As the Health Sector Reform agenda got underway, it was felt that a new approach to financing drug supply should be introduced. The Health Policy Framework Paper of 1994 placed the supply of drugs and medical supplies to the public health institutions high on the agenda in determining the quality of care. It has been observed that the regular availability of adequate supplies of drugs results in increased patient attendances and consequently confidence in the public health services increases.

4. Introduction: • In June 1994, the Ministry of Health sent a proposal to the Belgian Administration for Development Cooperation requesting for assistance with the establishment of a Revolving Drug Fund (RDF) to be piloted in Western Kenya. The main goal of the project was to “develop a new institutional framework within which an improved drug supply system can be effected”. Further consultations resulted in the selection of Nyamira District in Nyanza Province (Western Kenya). • Nyamira was chosen because it was a small district (896 sq.km) with few health facilities. It had a population of approximately 540,000 It also had a functioning infrastructure beginning with the district hospital as the referral level and ending with the dispensaries as the lowest level of care. Nyamira is divided into 7 administrative divisions within which are scattered 32 health facilities comprising 1 district hospital, 2 sub-district hospitals, 10 health centres and 19 dispensaries. The cost-sharing initiative was also in place and the communities were already accepting of the need to pay for health care. Finally being a tea growing area there was a sufficient level of economic activity to support a revolving drug fund. • The RDF Nyamira Project started on 1st February 2001 and ended on 31st January 2004.

5. Project Objectives • Three strategies were used in achieving the project goals: • The development of a new institutional framework within which an improved and efficient drug supply system could be developed. This was reflected in the establishment of an independent self-financing RDF • The second strategy was the development of improved financial and drug management systems focusing on the following areas: • Drug selection • Procurement • Storage and stock control • Distribution and • Accounting • Rational Use of Drugs was considered to be a key strategy in ensuring that supplies are ordered according to medical need.

6. Methods I ADMINISTRATIVE STRUCTURE: • The project activities commenced with the establishment of an administrative structure to ensure that the objectives as outlined were met. This structure comprised the following: • The Project Coordinating Unit headed by a Deputy Chief Pharmacist based in the Ministry of Health headquarters in Nairobi. This provided the link between the Ministry of Health, the Treasury and the Project. • The Sector Steering Committee also based in the MOH headquarters. This organ functioned as the policy making body taking major decisions on budgetary matters as well as the direction of the project. Its membership comprised the following: • From the MOH: The Permanent Secretary, Director of Medical Services, the Project Coordinator • A representative from the Ministry of Finance • A representative from the Belgian Embassy • A representative from the Belgian Technical Cooperation Department

7. Methods II • The Project Management Committee based in Nyamira District comprising 15 members taken from the Project Coordinator, the Project Manager, the District Health Management Team (DHMT), facility representatives and the BTC representatives (Country representative and Project Advisor). Its function was to ensure the overall and local implementation of the project • The Project Management Team also based in Nyamira was responsible for the day-to day management of the project. It was answerable to the DHMT. The team comprised the Project Manager, the Project Advisor (from BTC), the Project Coordinator. They were supported and the Project Staff COMMUNITY MOBILIZATION: • This was considered to be an essential step in the project implementation. The target population had to buy into the programme for it to succeed. The community infrastructure comprising organized groups such as health facility management committees, opinion leaders, clan leaders, local chiefs etc. was used to explain the purpose of the project to the community

8. Methods III COMMUNITY MOBILIZATION (CONTD.) • Divisional meetings (public meetings known locally as “barazas” were organized by the Project Management Team. In addition printed material in the form of posters in both English and the local language (Gusii) were prepared and distributed. A suggestions box was placed at each facility to allow for additional views. PHYSICAL INFRASTRUCUTRE: • The project required a state of the art storage facility. A district medical stores was constructed with adequate warehouse space and offices for the staff. A guest house was constructed so that visitors to the project could get acceptable accommodations near the project site. Storage space at rural health facilities were also rehabilitated to an professionally acceptable standard. The work included building of safes, repair of roofs and drainage for capturing rain water, improving security for the drugs and construction of waste disposal sites. The dispensing area for in-patients, out-patients and drug store facilities at the district hospital were also renovated as appropriate.

9. Methods IV DEVELOPMENT OF HUMAN RESOURCES • Following the secondment of MOH staff as project staff, training in the operations of an RDF were carried out. Once completed, the staff comprising the Project Advisor, Project Coordinator, pharmaceutical technologist and store man had completed their training, they proceeded to train the health workers in the district on the operations of an RDF. A total of 240 staff including medical doctors, clinical officers, nurses pharmacy and administrative personnel were trained. IMPROVEMENT OF THE PROCUREMENT SYSTEM • The District Health Management Team (DHMT) prepared a district essential drugs list per level of care based on the Kenya EDL in consultation with the technical staff of the RDF. Using a procurement agent, the project purchased the first consignment of drugs from the seed funds granted by the Belgian Technical Cooperation. The total value of drugs and medical supplies purchased was KShs 18 million (1 US$ = KShs 78). The first delivery had a monetary value of KShs 5.5 million. The procured drugs complied with all the regulatory requirements of the Pharmacy and Poisons Board.

10. Methods V DEVELOPMENT OF DRUG MANAGEMENT TOOLS • During the baseline survey, it was noted that the state of records in the pharmacy and stores left a lot to be desired. MOH registers, stock and bin cards, patients registers and exemption cards were redesigned and a system was put in place to improve inventory control at the facility level and the District Medical Stores (DMS). An operations manual for each facility and a training manual was also developed. A computerized inventory and financial management system was installed at the DMS and the district hospital. This was based on the commercial accounting package Quick Books and Excel. DEVELOPMENT OF A PROJECT MANAGEMENT AND MONITORING SYSTEM • The initial orders from each of the facilities were made on the approved order forms and covered a period of 3 months. Each facility was required to open a bank account at the beginning of the project. The drug “purchases” were done on a cash and carry basis. Cash was not actually exchanged on purchasing but proceeds from the sales of these drugs were banked in these individual accounts. Later in the life of the project the accounts were consolidated into a single account due to excessive bank charges.

11. Methods VI PRICING POLICY • Prices were set at a level that guaranteed sustainability. Expensive drugs prices were lowered and cheap drugs were marked up considerably which compensated for the discounted price of the more expensive drugs. The non-pharmaceutical items such as wound dressings materials were difficult to price thus a pricing policy was worked out on the basis of the procedures being carried out. All materials required for the procedures were included in the price. E.g. a simple wound dressing costs 25 KShs, stitching was priced at 100 KShs. • Vaccines, family planning anti-TB drugs were distributed free to patients as per Government policy. In July 2002, a change in government policy required that malaria patients be treated free of charge.

12. RESULTS • The project was able to sustain a constant supply of drugs for most of the 36 months in which the project was operational. • The cost of treating common diseases was drastically reduced compared to the cost-sharing programme and to the private market e.g. • Case: Adult with malaria • Px: • Sulfadoxine-Pyrimethamine (SP): 3 tabs • Paracetamol 500mg : 18 tabs Cost of treatment: Cost-sharing:RDF Cost per drug item = KShs 20 SP costs KShs 4 per tab = KShs 12 Complete treatment = KShs 40 Paracetamol costs KShs 10 for 18 tabs Total px cost = KShs 40 Total px cost = KShs 22 Private sector (lowest price generics, quality???): SP costs KShs 10 per tab = KShs 30 Paracetamol 18 tabs = KShs 36 . Total px cost = KShs 66

13. Results II • With the logistics support provided by the project, the RDF project staff were able to deliver drugs within 24 hours of receiving the regular quarterly orders from the facilities. Emergency orders were delivered same day as they were not so many of them. • Staff were able to carry out intensive monitoring and evaluation to ensure that revenue generated and drugs procured were being properly accounted for with minimal losses. This M & E does however require a heavy investment in personnel and logistics • The project was well received by the community who expressed concern about the next steps once the official project period ended on 31st January 2004 • The management of drugs from selection, procurement, distribution showed a marked improvement despite initial complaints about workload from the health workers. There was a general increase in job satisfaction as reported by a majority of the health workers. The project did however face a number of challenges especially regarding the attitude of certain health workers who found the strict controls a burden especially when former loop holes to leakage of drugs and revenue was closed. • Despite initial training on rational use of drugs certain irrational practices were observed which could possibly be attributed to the absence of Standard Treatment Guidelines in the health institutions e.g. In some institutions it was observed that the average total cost of treating malaria in adults was 3 times the district average. Further investigations revealed that some of the patients were being given 3 drugs such as Quinine injection, Amodiaquine and SP in addition to the paracetamol.

14. Conclusions and the way forward: • It has been shown that it is possible to establish a viable RDF programme at the district level provided there is a strong M & component in the activities • The Ministry of Health has proposed the expansion of the project into 15 districts forming satellites around Nyamira district. This will present some major administrative challenges. The idea has been well received as evidenced from a recently done feasibility study. A proposal is under preparation for the Expansion Phase of the Project. It is anticipated that the restructuring of the Kenya Medical Supply Agency will have reached a level where it can act as the procurement agent for the RDF programme. • The rational use of drugs remains a challenge. There is a need to carry out some comprehensive drugs use studies in order to identify problem areas. A prescription analysis was done in 2003 and the results are awaited, but preliminary results indicate that antibiotic use may need to be addressed. In addition the impact of introducing the RDF on RUD will need to be assessed scientifically. The MOH is about to launch the STG and KEDL 2003. A RUD training is being prepared in consultation with the with the Department of Pharmacy. However RUD is not really the core business of the RDF Programme although it was included as an activity. It is anticipated that this function will be taken up full under the revised National Drug Policy Implementation Programme. • Another key area of concern is how to take care of the needs of the poor who cannot afford to pay at all. The MOH is proposing to introduce the National Social Helath Insurance Fund. Further studies will need to be done to really identify the poor and to see how the RDF can tap into the NSHIF programme