Challenge
Approximately 77,000 children five years of age and younger die in Zambia every year, and an estimated 20% of these deaths are caused by malaria. While Zambia has had success with preventing malaria through mass distribution of treated bed nets and indoor spraying, the availability of essential drugs to treat malaria (and other conditions) at the public health facility level has been a challenge. Distribution from the district level to the health facility level was identified as the major bottleneck. The Zambia National Malaria Indicator Survey (2008) reported that just seven percent of children in rural areas under the age of five received pediatric Artemisinin-Based Combination Therapy (ACT)—the most effective first-line medicine for malaria—within 24 hours of the onset of a fever.
The Ministry of Health (MoH) and its partners have invested substantial amounts of money in the public sector supply chain in recent years. Despite these efforts, health facilities across Zambia continue to face difficulties accessing drugs and medical supplies in appropriate quantities. Significant problems include access to transport, lack of dedicated logistics staff in medical stores at the district level, and challenges in communication throughout the supply chain.
Approach
Acknowledging the challenges in secondary distribution and the frequent unavailability of drugs at the public health facility level, the MoH, in collaboration with partners, launched the Essential Drugs Public Pilot program in April 2009. The objective of the pilot program was to evaluate the comparative cost-effectiveness and operational effectiveness of two alternative supply chain models during a 12 month period (from April 2009 to April 2010).
The first pilot model, Model A, continued to hold stock at the district level, while introducing a Commodity Planner (CP) at the district level to enhance planning capacity. The second model, Model B, also had a CP, but eliminated the intermediate storage of drugs at the district level. Instead, the district store was converted into a “cross-dock”, or a point of transit, receiving shipments that are pre-packaged and sealed for individual health facilities. The pilot focused on peri-urban and rural areas and covered almost a quarter of Zambia’s 72 districts. To measure the effectiveness of the pilot, the program was accompanied by a rigorous impact evaluation.
Results
Results from the evaluation of the pilot program show remarkable improvement in access to all essential drugs at the health facility level, particularly in districts where Model B was implemented. For example, Amoxicillin, a frequently used antibiotic, was not available in 72% of the model B facilities at the start of the project, versus 16% after implementation of the intervention. Also, pediatric malaria drugs, which were found to be out of stock for an average of 29 days out of 92 days in comparison districts (where no changes were made in the supply chain) were out of stock for only 5 days. Various other aspects of the supply chain also improved, including better storage conditions, increased reporting rates on the delivery of drugs, and more effective supervision. Model B was also nearly four times as cost-effective as Model A with regards to stock availability.
A conservative estimate in 2010 showed that if Model B were scaled-up nationwide, under-five and over-five mortality due to malaria would decrease by 21 percent and 25 percent respectively, with thousands of malaria-related child deaths averted by 2015. Also, the aggregate household income loss averted is estimated to be more than US$1.6 million/year nationwide. This figure was derived using the concept of foregone income, whereby the value of lost workdays due to malaria was calculated based on estimated wages. It was conservatively assumed that on average 2 workdays would be lost for a sick adult, and another 2 days for an adult caring for a sick child. The long term economic impact is likely to be higher, as the estimate does not take into account the longer term economic consequences associated with malaria incidence such as death, increased morbidity, and impaired cognitive development due to malaria-related anemia in young children.
Bank Contribution
The pilot was financed through support from the World Bank Malaria Booster Program (US $20 million for the entire program), which includes funds specifically earmarked for supply chain management.
Partners
Recognizing the importance of strengthening the supply chain and improving access to treatment, the World Bank, UK Department for International Development and USAID partnered with the Ministry of Health in Zambia to support the pilot. Medical Store Ltd (MSL)/Crown Agents and John Snow International were the implementing partners of the pilot and the Massachusetts Institute of Technology (MIT) and the MIT-Zaragoza Logistics Program provided technical support. The involvement of several partners brought many different types of expertise to the table, including the application of private-sector techniques to public supply chain management.
Toward the Future
Overall, the financial sustainability of Zambia’s malaria program remains a challenge. As a result, the government requested additional World Bank financing of US$30 million (through IDA) in 2010 to scale up cost-effective interventions. This additional financing became effective in February 2011. Among other interventions, the government has indicated its intention to scale up improvements in the management of pharmaceutical supply chains based on the recommendations that emerged from evaluation of the pilot.
Beneficiaries
The project has received much positive feedback from beneficiaries, such as the following:
“In the past, we used to get a lot of prescriptions without access to actual medication,”said Mwansa Kasonde from Mungwi, 30 km from Kasama, in the Northern Province
“They would tell us to go and buy from drug stores whose price was exorbitant. These days, we get free medication from our nearest health facility.”
Oscar Bwalya, who works at the Rural Health Center explains that “Drug availability has improved tremendously, particularly anti-malaria and antibiotics. We now have the ability to order according to demand and this has ensured access to a variety of medicines by our community.”
“I look forward to this [the supply chain improvements] being scaled up across the country because we are telling a very successful story,” said Grace Nanyinza, from the public health center at Mungwi.
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