In response to shortages of TB drugs experienced in 2014, and to risks that have been identified of additional shortages for drugs used for all three diseases, Kenya has put in place various measures to reduce the risk of treatment disruptions.
In early 2014, Kenya experienced an acute shortage of TB drugs, specifically streptomycin and paediatric TB drugs, due to the failure of the counties to purchase TB drugs. This happened at a time when the central government was devolving major functions to Kenya’s 47 county governments – including the responsibility for health care – following the adoption of the new constitution in 2010. Counties took up the responsibility for planning and budgeting for their own health services. In an audit report released in July 2015, the Office of the Inspector General stated that the central government allocated money to the counties without providing timely guidance or capacity building in procurement or drug forecasting (see GFO article).
Though the number of stock-outs has gone down since 2014, John Kabuchi, procurement manager at Kenya Medical Supplies Authority, told GFO that some counties remain more at risk of developing stock-outs than others. KEMSA is the government agency whose mandate is to procure, warehouse and distribute drugs and medical supplies for certain public health programs. Kabuchi explained that political will and staff’s knowledge of basic inventory management techniques and data collection are two factors that may influence the frequency of stock-outs in the counties. In addition, conflict areas are more at risk of experiencing stock-outs because it is difficult to deliver commodities to such areas and carry out capacity building exercises.
Samuel Muia, oversight officer for Kenya’s country coordinating mechanism (KCM), added that environmental changes sometimes influence the frequency of stock-outs. For example, heavy rains in the western part of the country led to an upsurge of malaria last year. This, in turn, resulted in increased consumption of anti-malarials and stock-outs at the facility level.
The remedial measures implemented by Kenya are as follows:
- KCM Oversight Committee
- Oversight field visits
- Elimination of parallel drug supply systems
- Implementation of (a) the Logistics Management Information Systems (b) the Pull system
- Monthly commodity security meetings
Each of the measures is summarized below.
KCM Oversight Committee. In 2014, the KCM established an oversight committee to strengthen its oversight function. Among the responsibilities of the committee is ensuring transparent and effective procurement and supply chain management. One of the tools the committee uses is the CCM dashboard.
The dashboard is a visual, strategic summary of key information drawn from existing data sources for all Global Fund grant principal recipients (both government and NGO). It includes stock level indicators where current stock is measured against safety stock. Safety stock (also referred to as “buffer stock”) is the minimum stock level central stores and facilities should have at any one time to protect against stock-outs. In Kenya, safety stock for TB drugs, for example, is a 6-month supply, while for HIV drugs it is three months.
If the oversight committee spots a problem, or what it believes could be a potential problem, it will make recommendations to the full CCM concerning what actions could be taken.
Oversight field visits. Since its inception in 2014, the KCM oversight committee has embarked on field visits to witness how grants are being implemented. The field visits are usually conducted twice a year, but additional visits can be arranged if there is a perceived need. In May 2015, the oversight committee carried out a field visit to 16 health facilities in Homabay and Vihiga counties. These visits revealed stock outs of anti-malarials in a number of health facilities in both counties (see report).
Elimination of parallel drug supply. Over the years, various donors have utilized different procurement mechanisms for ARVs. These have now been integrated into one pipeline under KEMSA. This has helped avoid duplication and wastage.
Implementation of the computerised Logistics Management Information System (LMIS) and the Pull system. The LMIS is a system of records and reports used to aggregate, analyse, validate, and display data from all levels of the logistics system. These data are then used to make decisions and manage the supply chain.
KEMSA developed a web-based system which includes a self-service customer portal installed in all county health facilities. Through the portal, health facilities are able to submit consumption data as well as place drug orders. The portal has eliminated the long manual ordering process which could take weeks or months. In addition, it has reduced the amount of paperwork submitted by the facilities and significantly increased the quality of data. It has also led to improved quantification and planning of the national needs.
Although the more efficient web-based LMIS has been in existence for a number of years, not all health facilities have adopted it. Efforts are being made to ensure complete uptake of the web-based LMIS at the facility level. Kabuchi revealed that KEMSA has now been rolled out the web-based LMIS to all the 47 counties. In addition, KEMSA has carried out capacity building initiatives in more than 3,000 health facilities, half the number of all the 6000 health facilities served by KEMSA.
Increased uptake of the LMIS has contributed to the implementation of the Pull system. Through the LMIS, facilities have been given an opportunity to submit consumption data and “pull” for drugs they require in the quantities they need. The Pull system is replacing the Push system where KEMSA would deliver predetermined quantities and varieties of medical commodities to health facilities on a quarterly basis. The Push system was deemed to be wasteful because often commodities were sent to facilities that did not really need them.
Monthly commodity security meetings. Meetings at various levels have been set up to monitor and analyze national stock status. These meetings include the demand analysis team meeting, commodity security meetings, program inter-agency coordinating committees (ICCs) meetings and joint ICC meetings. According to Kabuchi, the demand analysis team meets monthly to monitor what drugs have come in and what has been used, and to project future drug needs. Through these meetings, potential stock-outs can be recognized and corrective action initiated early.
Despite these measures, challenges remain. According to Muia, needs assessment and commodity quantification at the facility level are fraught with challenges. There is poor data collection and under-reporting of disease cases and consumption at the facility level which often leads to under-estimation of the burden of disease. This makes it hard to make accurate forecasts of needs. “Counties should ensure comprehensive capturing of data as this has a direct impact on commodity quantification” said Muia who further proposed training to build the capacity of staff in the facilities in these areas.
Inefficiencies are still experienced at the county level. For example, where one facility in a county is overstocked in a particular drug while another facility in the same county is experiencing stock-outs of the same drug, there are no systems in place to enable redistribution from one facility to another.