WHAT IT TAKES TO REACH EVERY PATIENT
WHAT IT TAKES TO REACH EVERY PATIENT
Answering that question became the foundation of an enduring partnership between Management Sciences for Health (MSH), USAID, and country governments around the world. Over the past 30 years, as a result of that partnership, these countries have made monumental progress in building the systems that move medicines to their final destination: the people who need them.
Through videos and articles, Medicine Movers tells the stories of patients in Ethiopia, Kenya, and South Africa who continue to benefit from these systems, launched during the peak of the AIDS epidemic. All of these patients have faith that their grandchildren will see these systems continue to be strengthened and become valuable tools in the unfolding battles against epidemics and chronic diseases. Ultimately, Medicine Movers tells the story of improving health for generations to come.
Scroll down to meet Aster Amanuel Desalegn, who invited MSH to accompany her on a visit to the pharmacy at the local hospital in Debre Markos, Ethiopia.
Articles written by Daphne Northrop, videos by Emily Judem
improving pharmacy services in ethiopia
improving pharmacy services in ethiopia
Ultimately, some of these patients receive their medication. Others are too late; the stock bin is empty. Still others may have departed with just one of the several medicines prescribed to them.
Fast forward six years, same hospital. Patients are indoors, waiting on benches. At a single counter, in private booths, each patient moves quickly through a process of handing over a prescription, paying for it, and receiving it. The pharmacist can easily locate and dispense the needed medicines, and he doesn’t run out of anything. The visit is capped off by a private counseling session. Patients can ask questions, and they can hear the instructions the pharmacist gives about dosages and side effects. The pharmacist has received on the job training, so he can answer most everyone’s questions. When the manager asks him about quantities for the next delivery, he can quickly run an inventory report.
A new way of getting medicines to people has transformed this hospital’s pharmacy and hundreds like it around the country, to better help the thousands of Ethiopians who rely on public hospitals for care.
The Auditable Pharmaceutical Transactions and Services (APTS) system, developed by MSH in partnership with Debre Markos Hospital in 2010, and with funding from USAID, is a package of interventions that transforms the environment, dynamics, services, and resources within pharmacies. With APTS, pharmacies are renovated with enhanced patient services in mind. They have systems to collect information about medicines and patients, which make decision-making, ordering, and inventory faster and more accurate. They have tools to build staff skills and improve budgeting practices.
APTS is the culmination of decades of work that MSH has done in Ethiopia to get the right medicine to the right patients when they need it.
In 2010, APTS was piloted at Debre Markos Hospital, a remote regional hospital that serves a population of about 4 million. It immediately showed signs of success. The hospital’s selection of medicines began to more accurately reflect the community’s health needs, and patients were much more likely to receive what they came for: 97.5 percent of the requested medicines were on hand, up from 65 percent. Far fewer had expired—a mere .27 percent, down from 8.24 percent.
With more service windows, the hospital could double the number of pharmacists and serve more patients. Waiting time dropped significantly—what used to take a half-day now took about 20 minutes. Patients noticed. In 2008, patient satisfaction was 25 percent; by 2012, it was 85 percent, with medicine availability the most significant contributor. Surveys showed that knowledge about how to take medicines markedly improved.
The hospital was delighted with the increased sales, which increased revenues by nearly 90 percent between 2011 and 2012. Theft and waste plummeted, also improving the bottom line. And audits became less of a headache, now that there was a robust system to provide accurate, up-to-date information on transactions.
Health officials also took notice. Regional governments, federal health facilities, and city administrations clamored for APTS, and USAID provided MSH the resources to respond. The Federal Ministry of Health mandated APTS as state-of-the-art practice for the nation’s public hospital pharmacies, featuring it in the new Health Sector Development Program for 2015-2020—the document that sets future priorities in the country’s health sector. Countrywide rollout is underway and will include university and federal hospitals, which have long suffered from acute shortages of medicines and supplies. To date, more than 50 health facilities country-wide rely on APTS.
As Ethiopia prepares to respond to the coming surge in chronic disease and greatly expanded access to medicines and services, this system will be essential.
A few miles down the road from the hospital, Aster Amanuel Desalegn sits in her easy chair, softly smiling as her granddaughters Emaye, 6, and Blen, 8, shyly greet their visitors. Aster delicately fingers her gossamer white shawl as she starts to tell her story. She looks younger than her 70 years, and her clear eyes don’t betray everything she has been through. Diabetes. Tuberculosis. Arthritis. Breast cancer.
She has been getting her medicine at Debre Markos Hospital for almost 20 years. She recalls the early years, when she had recently been diagnosed with diabetes. Every visit to the pharmacy to replenish her insulin took at least a half-day and was filled with anxiety.
“We used to sit in the sun, in the rain, and get exhausted,” she says, her voice heavy with the memory. After all that waiting, there was always a chance the pharmacist would tell her that they didn’t have the medicine she needed. And if the public hospital didn’t have her medicine, her only option was to pay for it—with money she did not have—at a private pharmacy, where the workers may not have much medical knowledge and the medicine’s quality can’t be counted on. Once, she says, she had to instruct such a dispenser, who claimed to be a pharmacist, about the need to refrigerate insulin.
“These were the problems we faced before,” she says. “Now, we don't get told the hospital doesn’t have all the medicines we need.”
Earlier that day, she had zipped in and out of the hospital to get her monthly dose of insulin, which she could be confident had been refrigerated properly, and where she received counseling from the pharmacist. He reminded her of the importance of a low-sugar diet, and counseled her on when to use painkillers for her arthritis. He double-checked that she stores her insulin properly and knows what to do if the electricity cuts out.
“They don't skip the counseling service and send me home just because I go there all the time,” she says.
“To compare what it was like before and how it is now, there is such a big difference. There are seats where we can sit and wait. We get treated with respect,” she adds. She always gets what she came for, and she can count on being back home by midday.
“I am grateful I’ve lived long enough to see these changes,” she says with a sigh.
In Aster’s lifetime, Ethiopia’s population has quintupled, growing from about 18 million in 1950 to nearly 100 million as of 2015. She has seen the ravages of famine, war, and the AIDS epidemic.
But she has also seen her country rise to meet its health challenges. When she was born, almost 20 percent of children died before age five. By 2015, that statistic had dropped to 5 percent. Life expectancy for someone born in 1946 was 30; today it has risen to 65. And Aster has lived well beyond that.
But still, she is among the lucky ones, to have a high-functioning hospital so close by.
In any country, the pharmaceutical system—the movement of medicines from factory to warehouse, through distribution points to clinics and pharmacies, and finally to the patients in need—is largely invisible. It is also complex, even more so in countries with unrest, drought, or poor infrastructure. The transformation at Ethiopian hospitals shows what it takes to upgrade that system and keep it working well. It reveals what it takes to ensure a continuous, reliable flow of medicines to the people who need them, no matter the circumstances.
The creation of APTS built on 13 years of an MSH partnership with the Ethiopian government and USAID to implement successive improvements to the country’s pharmaceutical system. Many of these improvements emerged from the need to respond to the seemingly unstoppable scourge of HIV and AIDS.
In 2003, African countries were under immense pressure to quickly and efficiently get AIDS medications to a huge number of patients. In Ethiopia, the continent’s second largest country, an estimated 1.5 million people were HIV-positive.
Even if enough medicine had been on hand, the pharmacies were not ready. Long neglected, they were in disarray. There were no systems or records — for patients or for medicines. Crowded and chaotic, pharmacies were riddled with logistical and structural problems, using systems developed 100 years earlier. James D. Wolfensohn, then the president of the World Bank, had publicly called corruption — rampant in pharmacies — a “cancer.” It was impeding social and economic development, he cautioned, keeping millions of people trapped in poor health and poverty.
Only those who could pay at private facilities or buy smuggled medicine were receiving treatment. That year, 120,000 Ethiopians died from AIDS. Due to the social stigma associated with AIDS, many in need avoided the health care system altogether. Without the ability to talk with a provider confidentially, many patients never started, or dropped out of, treatment. And suffering most from these system weaknesses were the poorest and most vulnerable, whose access to medicines had been limited to begin with.
“There were about nine thousand patients, all of whom were getting their medicines in a very dubious way,” recalls Negussu Mekonnen, MSH’s country representative in Ethiopia. “People were selling their property to buy counterfeit antiretroviral drugs. There was a general sense of desperation.”
The tide began to turn after President Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 to provide antiretroviral (ARV) medications. By 2005 they were available for free. The goal was to get ARVs to 15,000 people that year.
But how could the country reliably get a steady flow of medicine to so many people without delay or interruption? An innovator in ensuring medicine supply in the developing world since the early 1990s, MSH, in partnership with USAID, was called upon to get the job done. The campaign ultimately resulted in a 50 percent reduction in adult AIDS deaths in the Ethiopian capital over the next five years.
“It was a very big assignment, a very urgent, life-saving assignment. The US government and the local [USAID] mission entrusted us with this responsibility,” says Mekonnen.
MSH rapidly took stock of the situation, collected data, and prepared remedies. A preliminary assessment showed that more than one-third of Ethiopian health facilities routinely ran out of essential medicines. More than 8 percent of medicines were expired, and only half of patients knew what the correct dosage was. If a pharmacy ran out of a medication in 2003, it took an average of three months to get it back in stock again. Meanwhile, other medicines that didn’t match the needs of patients sat on shelves and expired before they were used. No one was keeping accurate records of what came in and what was dispensed. Pharmacists’ jobs were laborious, with disorganized rooms, storage, and workflow. Theft was common. Without secure storage or a way to keep track of inventory, the high-priced, high-demand HIV medicines were in jeopardy.
At the beginning, as MSH ramped up the project, “I used to use my own private car to distribute some of the commodities,” Mekonnen recalls. “The job had to be done because people were dying. On one occasion, the guard of the hospital refused me entrance because he was suspicious that medicines were being delivered using a private vehicle. “
MSH went on to ensure uninterrupted supply of ARVs by establishing data and inventory systems and embedding these systems in more than 280 health care facilities across the country. By 2008, more than 400 hospitals and health centers were using standard forms for patient registration, tracking, and inventory control. By 2011, MSH had trained more than 8,000 pharmacists in more sophisticated approaches and practices.
These efforts made possible the uninterrupted supply of ARVs, even in the most remote areas of the country.
In 2009, free ART was reaching about 100,000 Ethiopians. By 2011, that number had more than doubled.
After the first urgent push to supply ARVs, MSH turned its attention to the next essential step: making sure that people stayed on the medicines. The lens broadened to take on recordkeeping of both people and their medicines. Pharmacies began tracking patients who had dropped out of treatment, and eventually, adherence, with its many facets, became a national priority.
MSH continued to evolve one of its early tools, the Electronic Dispensing Tool, to track medication errors, harmful drug interactions, and adverse reactions, which by 2012 had expanded to 165 sites. For the first time in Ethiopia, patient pharmacy medication cards for ARVs were introduced at all ART facilities (by then there were more than 500 such pharmacies), making treatment and follow-up data available for 200,000 HIV and AIDS patients. Those improvements, MSH saw, could now be expanded to improve the entire medicine delivery system in Ethiopia.
“You cannot sustain a system to serve solely a single disease,” notes Mekonnen. “So we went on to strengthen the entire system, the base of the pharmacy services. This was crucial.”
A few years earlier, Ayalew Adinew had joined MSH as a senior technical advisor. He had grown up near Debre Markos Hospital and eventually became a pharmacist.
“I worked in hospitals for 12 years. I saw theft, pilferage, expiry,” he says.
He could see firsthand that these problems were costing millions and devastating lives.
His hunches were born out by the data. An MSH assessment in 2009 showed that a third of designated ARV sites had lost medicines to damage, expiration, and theft, and only one of these pharmacies had a reliable system to record such losses. Smuggling and re-sale were rife. In 2010, stock-outs of essential drugs nationwide were at 35 percent, patients’ knowledge on correct dosage was at only 68 percent, and the national average rate of medicines expiry was nearly 10 percent.
Shortly after he joined MSH, Debre Markos Hospital CEO Shegaw Alemu and Chief Pharmacist Edmealem Admassu contacted Adinew. They were having a lot of problems managing the hospital's pharmacy. They said they heard that MSH could solve “systems problems.”
Adinew was the right man to call. He had given this a lot of thought.
“Without pharmacy service there are no health outcomes,” says Adinew.
He knew that these problems were not just apparent when it came to ARVs. They were an issue for public pharmacies treating patients for all health problems.
He approached his MSH team, and APTS, the comprehensive improvement package for hospital pharmacies, was born through a strong partnership between Debre Markos Hospital and MSH. Adinew remembers the day: June 10, 2010.
APTS started as a spreadsheet on Adinew’s computer. He and a team analyzed and recorded each step in all of the processes of a working pharmacy. They mapped out the flow of medicines and supplies through a health facility system. They created new tools and forms such as vouchers, sales tickets, and dispensing registers to organize and record information. The next phase was testing the new system, and Adinew returned to his hometown to see it through.
At Debre Markos Hospital, CEO Tariku Belachew had been spearheading a number of improvements since he had started the job four years earlier. The appeal of APTS was its multi-faceted approach—it had the potential to rectify many major problems he was facing, including waste, stealing, and poor communication with patients. The other asset, Belachew says, was the opportunity to partner with MSH.
“We wouldn’t have gotten here on our own. We wouldn’t have even started.”
Every regional bureau official and regional chief pharmacist has visited Debre Markos Hospital's pharmacy to see first-hand the transformation that APTS has brought. As word of Debre Markos pharmacy’s successes spread, APTS was quickly scooped up by other hospitals in the district, then in additional districts. With each successive hospital’s tweaks, the Ethiopian standard was established for storage, financing, dispensing, counseling, and training. In the first five months of APTS at five hospitals, three of them had 100 percent availability of medicines.
Currently 50 public hospitals—of about 200—have implemented APTS, and it is now required by the government for all new facilities.
“APTS is now the property of Ethiopian professionals. Why? Because many professionals of Ethiopia commented on it and their cumulative knowledge was put into the system,” says Adinew.
MSH had turned the climate from a commodities-focused system to a patient-focused system.
“MSH has really introduced a new culture of pharmacy practice in Ethiopia, where the patient is at the center of all the services we provide and patients are protected from unnecessary harm related to the use of medicines,” says Hailu Tadeg, country project director at MSH. “They are given services in a respectful manner with their dignities respected.”
The operation of a pharmacy may be almost invisible. But it is on the front lines of patient care.
“The pharmacy is usually the last contact a patient has with the health care system,” says APTS creator Adinew. “The last encounter creates the first impression.”
Scroll down to meet Faith, HIV-positive at 36, who tells MSH about how she recovered from an adverse drug reaction in Nairobi, Kenya.
ensuring medicine safety in kenya
ensuring medicine safety in kenya
“My health continued to deteriorate. I was weak and I did not know what I was suffering from. I could not go to work,” she says.
A friend urged her to get an HIV test. She was 31 and had two daughters. The test came back positive.
“I was traumatized. I wanted to commit suicide.”
Late one night she came perilously close. She had the poison on hand. But something stopped her.
“I looked at my kids,” she says, her eyes pained with the memory. “I felt sorry for them, because there would be no one to take care of them. They needed me more.”
That’s when the Eastern Deanery AIDS and Relief Program (EDARP), located near a crowded Nairobi slum, became her lifeline. She began taking antiretrovirals (ARVs) in 2011. Her appetite improved, and she grew stronger. Her viral load went down.
But that all changed in 2013 when one of her ARVs started to work against her, causing large misshapen fat deposits to develop on her body. The effect was so severe and disfiguring that she was embarrassed to walk outside.
“My body had changed. Before I started taking the medicine, I had small breasts. But when the medicine reacted negatively, they grew much bigger,” she says. ”My legs were so thin that you could see the bones.”
She was ashamed and hesitated to bother the doctor, she remembers.
“We receive the medicine for free. I did not want to seem like I was complaining.”
When she finally mustered the courage to speak up one year later, her doctor knew just what to do. He had seen this before. She was experiencing lipodystrophy, a side effect of the antiretroviral drug stavudine. This reaction was so common that the World Health Organization recommended in 2009 that stavudine be phased out of use. Because of its low cost, plentiful supply, and effectiveness — and despite its debilitating side effect — it was still being used in some parts of the developing world. Faith’s doctor shifted her to a different medicine.
“When my ARVs were changed, my body gradually went back to normal, and I had no worries,” she says.
Faith didn’t know it, but her report to the doctor became part of a nationwide database that tracks adverse drug reactions, and poor quality or expired medicines. Developed by MSH in 2009, with USAID support, the tracking system is the product of a long-established partnership between MSH and the Kenyan government. It is embedded in the public health system, allowing the government to track patterns and problems, develop better detection and response efforts more readily, and ultimately nip problems like Faith’s in the bud.
The system became digital in 2013 and will ultimately make paper-based records a thing of the past. The digital application can be downloaded on computers and smartphones, and reports of medicine problems can be logged on the website of Kenya’s Pharmacy and Poisons Board, the national agency overseeing medicine regulation, quality assurance, and patient safety.
With this “pharmacovigilance” system, Kenya became the first country in Africa—and in the world—to use a digital medicine quality and safety reporting tool available online and via mobile technology.
As of March 2016, all of Kenya’s 47 counties were reporting into this system, and the government had received more than 8,500 reports of suspected adverse drug reactions and more than 750 reports of suspected poor quality medicines. With this frontline data, the Pharmacy and Poisons Board has taken a variety of immediate actions: quarantining low quality or substandard medicines; recalling some medicines; changing labels; inspecting manufacturing practices; and, in one case, closing a pharmaceutical company that was not up to standards. The data has also been used in the review of treatment guidelines.
“There should be no compromise when you’re talking about drug quality,” says Joseph Mukoko, deputy project director at MSH. “Our main focus is ensuring that the patient gets maximum benefit from whatever is available.”
Kenya’s Ministry of Health credits the system with reducing suffering and saving lives.
“An ineffective medicine and an unsafe medicine can kill you. [Without] efficacy and safety of medicines, they will just do the opposite of what they are supposed to do,” says Josphat Mbuva, senior deputy chief pharmacist at the Ministry of Health.
Adverse drug reactions like Faith’s are but one stubborn problem with medicine safety in Kenya. Low quality drugs, lax regulations, and smuggling are all too common. A recent study by the Kenya Association of Pharmaceutical Industry reported that counterfeit drugs account for about $130 million (USD) in sales every year.
Bad reactions can have disastrous consequences for patients and consume huge portions of the health care budget. They are the cause of 10 percent of hospital admissions globally, according to the World Health Organization. Nationwide figures are not available for Kenya, but in 2015, the 1,800-bed Kenyatta National Hospital in Nairobi reported that about 10 percent of its patients had experienced adverse drug reactions.
Even if the bad reaction itself does not cause irreversible harm, it causes many to simply stop taking the medication. With an aggressive disease like HIV, stopping medicine in the middle of treatment can have deadly results.
These reactions are not inevitable consequences of taking medicine; overall, 60 percent of adverse drug reactions are preventable. And the bedrock of prevention is accurate data about the extent and nature of the problem.
Since 2003, Kenya has seen a huge increase in the availability of medicines, particularly ARVs, thanks to The Global Fund to Fight AIDS, TB, and Malaria and the US President’s Emergency Plan for AIDS Relief (PEPFAR), says Ndinda Kusu, deputy project director at MSH.
While the infusion of medicine saved hundreds of thousands of lives, it also revealed gaps in the country’s pharmaceutical system.
The problem was that “access had not been matched with a system to monitor the quality and the safety of these products in country,” Kusu says.
The free, steady, and effective HIV treatment that Faith has received was unimaginable in 1993, when nurse Alice Njoroge founded the EDARP Clinic, where Faith now goes for medical care. The clinic’s trajectory mirrors the evolution of Kenya’s response to AIDS.
At that time there was no HIV treatment available in Kenya; there were only antibiotics, antifungals, and painkillers to treat symptoms. Patients were feared and shunned. Njoroge said she was horrified to see what happened to patients—they were sent home to die, often abandoned by their families.
“The relatives were so scared. You would go into a home, find a patient who is very, very sick and uncared for,” she says. “Nobody would go near to feed them.”
With assistance from the Catholic Church, Njoroge founded EDARP to help families provide palliative care for their loved ones.
“We trained volunteers to give home-based care, to bathe those patients, to feed them, and to at least make sure the patients were comfortable so that, though we knew they would die, they would die in dignity,” Njoroge says.
Nearly 25 years later, the EDARP Clinic has evolved into a full-service HIV and AIDS treatment facility serving 25,000 adults and children.
By the end of 1999, about 2.1 million Kenyans were living with HIV, with 180,000 deaths that year. HIV medication was unavailable in Africa, but it was on the horizon.
In 2001, MSH was selected to take part in a USAID pilot study to determine what it would take to get the medicines distributed to Kenyans on a large scale, in huge volume, and at an unprecedented rate.
MSH proposed that existing laboratory and pharmacy systems serve as the basis for rapid start-up, be fixed where weaknesses appeared, and be improved as soon as possible.
The test run would take place in Mombasa, a coastal city with a population of about 500,000, approximately 300 miles from the capital of Nairobi. MSH began with a rapid assessment, working with three other international development organizations and local staff to understand the context and potential barriers. Together they established baseline measures, sized up the capacity of the system to manage the volume, and assessed existing pharmaceutical and laboratory services to see if they had the needed capacity.
MSH’s assessment revealed obstacles aplenty: only 13 percent of facilities had adequate storage and dispensing space, none had efficient information systems, and only 42 percent of health workers were trained to dispense ARVs. Paper-based pharmacy records didn’t provide enough information, jeopardizing patients’ ability to adhere to treatment. Staff training was inadequate and the number of health workers often was insufficient. Facilities were crowded, making confidential counseling impossible.
Pilots launched in 2002 at four sites in the city. Continual refinements improved staff abilities to manage supply, deliver treatment, and build skills. MSH created and introduced an electronic dispensing tool that eliminated cumbersome paper records, which was eventually enhanced to accurately monitor early warning signs of drug resistance.
With resources from PEPFAR and the Global Fund in hand and successful pilots, the Mombasa clinics began officially distributing ARVs in 2003. It was the first such public program in the country, paving the way for nationwide roll-out. That year, only 6,000 people were receiving ARVs—five percent of those who needed them.
MSH worked hand-in-hand with the government to improve the system and with USAID to negotiate prices and procure ARVs, helping clinics train and retain staff, integrating ARV therapy into existing services, and creating dispensing booths with more privacy for patients. MSH created other tools, including a medication counseling checklist, pointers on the importance of treatment adherence, and information on potential drug interactions and side effects.
Njoroge’s clinic started offering ARVs in 2004. By 2006, they were made available for free in public hospitals. By 2013, the percentage of Kenyans receiving ARVs who needed them had risen to 80 percent.
“If there’s anything that has happened that was a real blessing to this country and [all of] Africa, it’s the availability of ARVs,” says Njoroge.
MSH and the Kenyan Ministry of Health soon learned that getting ARVs to patients was not enough. As more ARVs were distributed, more bad reactions to these ARVs were happening, and there was no system in place to report them.
“The ART program in Kenya started in 2003 and we were scaling up,” recalls MSH’s Kusu. “By 2006, 2007, 2008, we were already getting patients who were … experiencing adverse drug reactions. And the country did not have a national system to systematically monitor and document these undesired effects.”
Medicines “need to be monitored very closely,” says Mbuva of the Ministry of Health. “Medicines can be useful and they can be harmful. Any medicine is a potential poison.”
For Mbuva, a strong pharmaceutical system that monitors safety, effectiveness, and quality delivers the all-important outcome: “It translates to better service provision to the people.”
MSH and pharmacies began building the layers, slowly creating a system: a modernized set of regulations, public awareness campaigns, identification of willing participants among the country’s pharmacists, and training for medical professionals.
When the surveillance system was launched in 2009, it featured yellow and pink paper—yellow for adverse drug reactions and pink for poor quality medicines—filled out by hand. They were delivered to the pharmacovigilance office by courier.
Aiming to improve timeliness and cost and ensure sustainability, the Pharmacy and Poisons Board, assisted by MSH, worked with local software developers to build a program that would be easier to use. The Pharmacovigilance Electronic Reporting System, launched in 2013, uses a web portal that is accessible via computer or mobile device. The data links directly to the World Health Organization’s International Drug Monitoring Programme, which tracks early warning signs of trends in medicine quality and safety.
Three years later, reporting of adverse drug reactions and poor quality medicines in Kenya is 80 percent electronic. It is more cost-effective and prompt, and reporting is easier. And the system continuously is enhancing the database for future reference.
Kenya’s advances in drug safety have been so significant that in 2014 the New Partnership for Africa’s Development, a 15-year-old African economic development program, awarded Kenya the distinction of being a Regional Center for Regulatory Excellence in Pharmacovigilance, positioning it as model in the region. Professionals from all over the world now come to Kenya to learn about the system that not only delivers the drugs, but ensures their safety, and increases the likelihood that people will stay on their medicines for as long as is needed.
The tools, standards, procedures, and training developed in Kenya have been passed along to 11 other countries: Cote D’Ivoire, Ethiopia, Haiti, Lesotho, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Vietnam, and Zambia.
The interdependence of health care at the community, county and national levels will be the lifeblood of Kenya’s sweeping devolution process, which aims to replace a strong executive government concentrated in Nairobi with one that shifts power and resources closer to the communities and citizens. Launched by the new constitution in 2010 and officially underway in 2013, the initiative, which has built a new structure of county government, is one of “the most rapid and ambitious devolution processes going on in the world,” according to the World Bank.
Its impact on health is potentially momentous. Many needs are unmet among marginalized or rural populations who are not represented in the data or decisions of a highly centralized government. With more resources in the counties, advocates of devolution believe, local health care needs will drive decisions and resource allocation.
They say the same promise holds for the nation’s pharmacovigilance system. When all of the country’s pharmacies and citizens are participating, the benefits Faith experienced will be possible to all Kenyans, no matter where they live.
“I am much better now,” says Faith. “Before, I was so weak and down with no hope. But now, I hope to live more than 50 years.”
She smiles as she thinks about her children, now 18 and 13. She now has a new goal.
“I hope to live and see my grandchildren.”
Scroll down to learn about South Africa's effort to make health care access and resources more equitable.
equal access to medicine in south africa
equal access to medicine in south africa
The squiggly Alime, who traveled that morning on his grandmother’s back to the hospital, happily munches on a cookie while the pharmacist counsels his grandmother on when he should take each of his medicines and how much to give him. It’s hard to believe such a tiny boy needs so many pills to survive.
Alime has been HIV-positive since birth. His treatment seems to be working. His weight has doubled, and as he smiles and gurgles quietly in Cynthia’s arms, he looks like a healthy toddler. He rarely takes his eyes off his grandmother, and he reaches out to touch her face as she talks.
Alime’s mother died of AIDS when he was just five months old, Cynthia says, her voice catching and grief pooling in her eyes. Now it’s up to her to care for her grandson.
So each month, they come here to Frere Public Hospital in East London. The trek takes most of the day, but Cynthia says she doesn’t have to wait long to see the pharmacist, and she always returns home with the medicine Alime needs.
She doesn’t know it, but one of the reasons for this is a tool called RxSolution. Though invisible to patients, it has transformed their experience at Frere and many other South African public hospitals, which treat the neediest and most vulnerable and were long-neglected during the country’s 46 years of apartheid. Developed by MSH with funding from USAID and the Eastern Cape Department of Health, RxSolution helps pharmacists easily monitor inventory, track patients, and aggregate data for planning and purchasing. It relieves pharmacists of time-consuming paperwork and allows them to spend more time with their patients.
Sammy Meintjes, lead pharmacist at Frere, still marvels that record-keeping tasks that used to take weeks can be accomplished in less than five minutes. He sees a direct connection between that and the quality of care patients receive.
“The more time you spend on a prescription, the less time you have to spend with the patient,” he says. “I think the system has really taken us to another level … we are moving in the right direction.”
Rolled out in 2004, RxSolution has been endorsed by the National Department of Health as the preferred monitoring system. It is used in more than 400 facilities across South Africa, including hospitals, community health centers, and primary health care clinics. Fifty-one percent of South Africa’s public hospital pharmacies have installed it, and almost 800 pharmacy staff members have been trained in its use.
On July 14, 2016, MSH reached an important landmark: officially handing over RxSolution to the government to be employed and sustained nationwide. Hospitals in five other nations—Haiti, Namibia, Rwanda, Swaziland, and Uganda—have also adopted the tool.
And the timing is propitious. Public hospitals are now in the spotlight, as they will form the backbone of the pending National Health Insurance plan that aims to provide access to quality health care to all South Africans.
The disparate conditions between public and private health systems in South Africa are a stubborn vestige of apartheid, when the government focused almost exclusively on economic and health advances for whites.
“The private sector was servicing the privileged white communities whilst the previously disadvantaged communities were still being serviced from the public sector … and that largely remains the case even today,” says Gavin Steel, chief director of sector-wide procurement at the National Department of Health. “[The public hospital system] was largely a chaotic environment that we inherited from the apartheid regime.”
The gap between the rich and poor in South Africa is among the largest in the world, according to a 2014 New England Journal of Medicine review. In health care, inequalities are especially stark.
While much progress has been made, serious health threats plague the country—many of them associated with poverty. South Africa’s unemployment rate is one of the highest in the world and rising, reaching almost 27 percent in early 2016. Tuberculosis is at epidemic proportions, and non-communicable diseases—diabetes, cancer, chronic respiratory conditions, heart disease—are beginning to gain a worrisome foothold. Violence and injury take a steady, high toll. And 6.8 million South Africans are living with HIV — a number higher than any other country in the world.
Pharmacist Meintjes is on the front lines. South Africa’s 400 public sector hospitals serve 84 percent of the population, most of whom are poor, with just one-tenth of the resources available to the private sector.
About 800 prescriptions are handled every day in Meintjes’ 34-ward hospital. Getting the right medicine to patients when they need it is the bedrock of his profession and his driving personal mission. And RxSolution helps him to do that, he says.
“Before RxSolution, we dispensed manually. The challenges we had were huge,” Meintjes says, recalling the time-consuming tasks of deciphering handwritten prescriptions, writing out labels, and making sure label and prescription information matched. It was a tedious, high-stakes job, which made it hard to retain staff.
“If the label is not clear, the patient can take the wrong dose … and it could have serious consequences,” he says.
RxSolution was piloted at Frere Hospital in 2002, and it has now become one of the engines of continual improvement in patient care and medicine safety. Pharmacy staff can use the system to track medicines from their delivery to the hospital stock room, to their arrival at the pharmacy, to dispensing to a patient. The electronic system also allows pharmacists to track patient histories and monitor their varied prescriptions and dosages. All of this adds up to safer regimens, which means patients are more likely to stay on their medicine and feel better.
“Ultimately no sound decision can be [made] without relevant and accurate information, so I think that’s the most important role of RxSolution,” says Stephanie Berrada, deputy country project director at MSH. It allows hospitals to track pharmaceutical expenditures, budgets, and inventory.
The system’s efficiency shows in Frere’s outpatient pharmacy, which hums with steady activity. More than 20 people sit in the waiting room and a half dozen pharmacists call patients to the dispensing windows. Behind them, shelves are full of medicines and supplies. Staff bustle around the central work counter, using RxSolution-enabled computers and printers to track, label, and package the prescriptions.
What used to be a three-hour wait for patients is now 45 minutes.
In just one year, between 1999 and 2000, more Africans died of AIDS than in all of the wars on the continent, according to the then-UN Secretary General Kofi Annan, who likened the epidemic to World War III. Twenty-three million sub-Saharan Africans had the disease at the turn of the century, and South Africa was affected more than any other nation. Twenty percent of the country’s population was infected and about a quarter of a million people died of AIDS in 1999, according to UN statistics.
By 2003, the South African government agreed to make ARVs available in public hospitals, supported by funds from the President’s Emergency Plan for AIDS Relief (PEPFAR).
The Global Fund to Fight AIDS, Tuberculosis and Malaria, which had been formed in 2002, was ready to make similar commitments but would only do so if it was assured that its investment would be protected by a strong medicine monitoring system.
At the request of USAID, MSH set out to create such a system. MSH had been working to strengthen South Africa’s public health sector since 1997. One of its first innovations was RxStore, a tool developed in 2001 with local software developers. With RxStore, pharmacists began to get a handle on stock levels and could discard their paper-based systems.
In 2000, Steel, of the National Department of Health, was working as a pharmacist at Frere Public Hospital, where Sammy Meintjes now works. The pharmacy was routinely running out of medicines, and the issue made local headlines. Steel wanted a better system, so he reached out to MSH. Together they started building the tool that would eventually ensure that Alime’s medicines were ready when his grandmother came to pick them up.
They drew upon MSH’s first-of-its-kind bulk-purchasing system developed in the Caribbean in the late 1980s and the successes of RxStore in 2001. Within six months, they had the prototype for RxSolution.
Steel, by then an MSH employee, and his colleagues at Frere Hospital put the system to use, and paired it with other systems strengthening activities—improved pharmacist training and supervision, record-keeping, and data collection. In just two months, the hospital was no longer in the newspaper, and stockouts became rare.
“What [MSH has] simply done is gone into a country, look at the tools that they are using, what are the challenges … then we say to them, ‘maybe we should look at doing it this way,’ and we develop the new tool together,” says Bada Pharasi, MSH’s country representative for South Africa.
By 2004 the expanded RxSolution was ready, improved over the years with the input from the pharmacists who were using it. The tool would support the unprecedented infusion of medicine to treat HIV.
Heidi van Rooyen, a pharmacist at Rustenberg’s Job Shimankana Tabane (JST) Hospital, has used RxSolution since 2005. She credits MSH’s staff, many of whom are trained pharmacists, with easing the pressure of caring for more than 5,000 patients.
“They have helped us help ourselves,” van Rooyen says. “If [MSH staff] weren’t pharmacists, they wouldn’t really understand what we need.”
A 2013 report confirmed her impressions: facilities that were using RxSolution were outperforming those that were not. So the government asked that RxSolution be introduced in all of the country’s public hospitals.
“RxSolution is most probably the heartbeat of our supply chain,” says Steel.
It ensures that patients get the medicine they need when they need it, helps hospitals track expenditures, and provides more equitable access to healthcare for all of its citizens.
To ensure uninterrupted flow of medicines, the South African government has taken the next step and asked MSH to develop a nationwide electronic surveillance system that will provide decision makers with up-to-the-minute information on inventory across all facilities, enabling immediate troubleshooting and solutions to problems with supply. By the end of 2016, data from 103 hospitals will be interconnected via a shared electronic dashboard.
Universal health coverage is the dream of South Africa’s health sector. Achieving it for the nation’s 54 million people would be an epic accomplishment, and tools such as RxSolution will play a leading role.
Supporters are laying the groundwork and taking the first essential step: improving the public hospitals and positioning them to offer services at the level of private facilities. While much progress has been made since the days of apartheid, there is plenty of work to be done. Inspections in 2014-2015 by the Office of Health Standards and Compliance showed that 67 percent of public health care facilities were non-compliant or critically non-compliant with the expected norms and standards.
By the end of 2015, the white paper on a National Health Insurance plan, a precursor to legislation, was released after years in the works. With its 14-year timeline, the plan is ambitious, calling for health coverage for all, quality services for people irrespective of their socioeconomic status, pooled funds and purchasing, and increased support for public sector facilities.
Acknowledging that the plan will call for “massive reorganization,” the government evokes the principles that created the country’s democratic political system in the early 1990s. Accomplishing national health insurance, the white paper says, “is a reflection of the kind of society we wish to live in: one based on the values of justice, fairness, and social solidarity.”
“Under [national health insurance] there is going to be one health system, so this artificial divide between the private and public sector will no longer prevail,” says Steel.
And that’s one of the reasons he does this work.
“One of the reasons why I personally got involved in the development of RxSolution was to improve equity,” he says, “and make sure that whether you present in Cape Town, or the Eastern Cape in East London, or Idutywa, or Butterworth, you get the same package of care.”
On her way out of the pharmacy, Cynthia glances over her shoulder with a smile. The white plastic bag full of medicine swings from her arm. Alime has already started to nod off.