Access to essential medicines remains a challenge in most developing countries and is among the Millennium Development Goal targets. Over the past decade, international organizations including the Global Fund, the World Bank, USAID have invested in improving access to essential medicines.
Laudable as these efforts are, making commodities available is not enough to improve the quality of life for most communities. Access must be tied to functional supply chain management systems, which enable efficient procurement, distribution and rational use of life-saving medicines.
These systems remain weak in many resource-limited countries, particularly in sub-Saharan Africa, despite years of investment in their improvement.Whether it is technical assistance, for system strengthening or capacity building, these investments have had limited impact in improving supply chain efficiency.
Perhaps it is time to consider a deviation from the traditional pathways, noting the lessons learned from successes around sub-Saharan Africa. Such successes may be attributed to local efforts (political will) married with technical and financial support from partners who have long supported supply chain programs at the central level.
Yet the challenges in supply chain systems are not limited to medical stores: on the contrary. In most countries, supply chain management systems continue to lack the requisite human resources. With the exception of South Africa, most countries in the region rely on inadequately trained or qualified personnel to carry out core duties in managing medicines and related commodities.
In Malawi, medicines are dispensed by assistants with no training in dispensing functions, while in Liberia some of the dispensers who manage medicines at service delivery points have less than seven years of formal education. Nurses and midwives shoulder most of the supply chain functions at the health facility level, yet the majority of them have not receive any training on how to manage medicines. Most of the skills and functions are learned on the job. Over the years TA agencies have often intervened with short training courses. It now appears, however, that those courses have had limited long-term impact.
Supply chain management requires both technical and managerial skills. Technical skills focus on product handling, while managerial skills deal with planning and managing the resources. Both of these sets of skills rely on complete and reliable data: another major hurdle limiting the efficiency of supply chains and having resultant consequences for policymaking, forecasting and budgeting. Many countries are hampered by a system-wide lack of reliable data, from the central down to the smallest service delivery units.
Accurate quantification of needs is critical to ensure that sufficient stocks are available at the right price and in good time.
For the Global Fund and other donor-funded programs, the preparation of procurement and supply management plans (the key tool to monitor the performance of grants) require that commodity needs are quantified based on consumption data. Yet analysis of existing grants shows that many countries still use issues data as a proxy for consumption to quantify needs.
The time for a paradigm shift is now.
Global advocacy for supply chain efficiency is high, with strong champions in the People that Deliver Initiative and the Reproductive Health Supply Coalition.
Most crucially, implementing countries are demanding change and demonstrating their willingness to contribute to new solutions to their old supply chain management problems. Rwanda, for example, has designed an integrated supply chain system that manages most commodities from a central repository down to the service delivery points. This approach seems to be serving the country well with few to no stockouts of essential medicines and related commodities at facilities.
Lastly, there must be a new approach to capacity-building. Technical assistance must invest more in data management for commodities to improve service delivery and forecasting. The current approach to capacity-building in supply chain management relies on workshops and training. In reality, individual skills are only one of the ingredients contributing to capacity to perform certain functions effectively and consistently over time. Individual health workers, no matter how skilled, are unlikely to deliver essential medicines or services effectively without adequate supplies and equipment, proper motivation and management support, and a good relationship with the community served. Capacity-building services are required for all of these areas to ensure performance goals are achieved.
Translating skills learned into sustained performance often requires new or improved capabilities in individuals and organizations alike. Capacity in this sense represents the potential to use resources effectively and to maintain gains in performance with gradually reduced levels of external support. The success of capacity-development efforts is limited by a focus on technical factors, while critical social and political barriers are ignored.
Training is not a “magic bullet” but it is still important. In building capacity in supply chain management, sustainable training should begin with developing appropriate curricula for different performance levels and targeting the various cadres involved in supply chain functions. These include pharmacy programs, pharmacy technician programs, and, in some instances, nursing programs.