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SUMMARY OF
STUDY FINDINGSDEEP DIVE ON THE IMPACT OF GOVERNMENT PROCUREMENT
PROCEDURES ON ACCESS TO PHARMACEUTICALS
OMONDI ...
PURPOSE OF STUDY
Understand the effect of lapses
in procurement systems on
access to health services;
Suggest actions that...
Examine
challenges
faced by health
facilities in
Kakamega
Propose simplified
health procurement
procedure guide for
effect...
01
02
03
04
05
06
Key Informant Interviews
Desk Review
Inception & Planning
Rapid Health
Systems Budget
Review
Focused Gro...
THE CONTEXT
IFMIS
Governments official payment mechanism
whose purpose is to improve
accountability and efficacy in the
payment for pu...
NATIONAL GOVERNMENT
National referral health facilities
Health Policy
COUNTY GOVERNMENTS
- County health facilities and
ph...
Population
estimated at
2,028,324
Poverty level
of 57%
Size 3,050
square Km, 12
sub-counties;
Pop 17.4% under 5;
26.3% chi...
176,247
111,574
177,080
138,298
115,677
113,429
154,481
161,977
123,627
151,591
226,743
184,579
180,709
114,398
181,563
14...
Indicator World National Western
Life expectancy at
birth (years)
59.7 58.9 48
annual deaths (per
1,000 persons) –
Crude m...
Causes and Risk Factors for MORBIDITY Causes and Risk Factors for MORTALITY
# Condition Risk Factors # Condition Risk Fact...
Type of health facility # Percentage
County hospital 1 0.4%
Mission/NGO hospitals 9 3.6%
Private hospitals 1 0.4%
Nursing ...
• General Staff shortage across all cadres;
• 51% of population not within 5km of health facilities;
• Basic Equipment in ...
▪ General Staff shortage across all cadres;
▪ 51% of population not within 5km of health
facilities;
▪ Basic Equipment in ...
THE FINDINGS
• Absence of definite government guidelines on proportional allocations to the
health sector;
• Poorly managed transfer of...
BUDGETING
Quantification&
Projections
FACILITY
Orders Generated
SUB COUNTY
Rationalization and Filtration
COUNTY PHARMACIS...
Process in accordance with good practice but there are gaps in
practice;
▪ Delays in quarterly dispatches leading to stock...
• Based on the County’s expenditure projections, the county health sector
would annually require an average of KES 971,796...
Health Care Functions 2013/14(KSh) 2014/15(KSh) % Change
Capital Formation 1,639,393,838 522,288,487 -68.1%
Governance, He...
0 500 1,000 1,500 2,000 2,500
Capital Formation
Governance ,and Health System and Financing Administration
Inpatient Curat...
THE RECOMMENDATIONS
1. Increase in Budget Allocation to
Pharmaceuticals
An average deficit of 53% in the
quantities of medicines required
mean...
2. Additional Pharmaceutical Personnel
There is an inadequacy of pharmacists and pharm-
techs yet this is a critical facto...
3. Improvements in the Procurement Process
It is possible for the county’s financial structure
to consider decentralizing ...
4. Investment in the Storage Infrastructure
For elements a, b and c above to be
effective, it is imperative that the count...
5. Strengthen Monitoring & Spot Checks
The commodity security technical working
group and the County and Sub-County
Health...
6. Focusting and Quantification
(F&Q)
In addition to the budget for
epidemiological emergencies, there is
need for accurat...
7. Community Participation
There is also need for a grassroots driven
Community Health Technical Working Group
(CHTWG) to ...
In suggesting an alternative procurement model,
the fundamental questions would often be; what
are the gaps in the existin...
Discussions….
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Impact of Government Procurement Procedures on Access to Pharmaceuticals - Summary of findings

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In Kenya, County level health systems continue to face challenges that have far reaching effects on citizen’s access to essential health services . Health sector remains a major beneficiary of the national and county budgets, yet there remains critical gaps in the pharmaceutical supply chain which continue to pose significant threats to the access of healthcare services.
The purpose of this study was to critically analyse county government procurement procedures (using Kakamega as a case County) with the intent of mapping the direct effect of lapses in procurement systems on the supply and adequacy of pharmaceuticals, and suggest actions that will contribute to improvements in the supply chain.

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Impact of Government Procurement Procedures on Access to Pharmaceuticals - Summary of findings

  1. 1. SUMMARY OF STUDY FINDINGSDEEP DIVE ON THE IMPACT OF GOVERNMENT PROCUREMENT PROCEDURES ON ACCESS TO PHARMACEUTICALS OMONDI OTIENO, MPH
  2. 2. PURPOSE OF STUDY Understand the effect of lapses in procurement systems on access to health services; Suggest actions that can contribute to improvements in the quality and access to basic health services. Highlight Contextual issues that have an effect on the adequacy of (non-) pharmaceuticals
  3. 3. Examine challenges faced by health facilities in Kakamega Propose simplified health procurement procedure guide for effective procurement and disbursement of health supplies Analyze procurements and disbursement specific - and related - policies and legislations Analyze actual health expenditure on Pharmaceuticals SPECIFIC STUDY OBJECTIVES
  4. 4. 01 02 03 04 05 06 Key Informant Interviews Desk Review Inception & Planning Rapid Health Systems Budget Review Focused Group Discussions Validation STUDY PATHWAY
  5. 5. THE CONTEXT
  6. 6. IFMIS Governments official payment mechanism whose purpose is to improve accountability and efficacy in the payment for public goods and services Devolution Health Services devolved to counties to create a robust health system that is responsive to the unique needs of populations Health Governance The management of various components of health care. Citizen Participation Anchors preventive health initiatives and drives uptake of clinical services . OPERATIONAL ENVIRONMENT National Health Act Prescribes the architecture of healthcare in Kenya 1 2 3 4 5
  7. 7. NATIONAL GOVERNMENT National referral health facilities Health Policy COUNTY GOVERNMENTS - County health facilities and pharmacies; - Ambulance services; - Promotion of primary health care; - Licensing and control of undertakings that sell food to the public; - Veterinary services (excluding regulation of the profession); - Cemeteries, funeral parlours and crematoria; and - Refuse removal, refuse dumps and solid waste disposal. Functionsareeither;exclusive,concurrentorresidual DISTRIBUTION OF FUNCTIONS
  8. 8. Population estimated at 2,028,324 Poverty level of 57% Size 3,050 square Km, 12 sub-counties; Pop 17.4% under 5; 26.3% child-bearing women; 47.1% under 15, and 4.7% over 60. FACTS & FIGURES
  9. 9. 176,247 111,574 177,080 138,298 115,677 113,429 154,481 161,977 123,627 151,591 226,743 184,579 180,709 114,398 181,563 141,799 118,606 116,301 158,391 166,078 126,756 155,428 232,484 189,252 185,284 117,294 186,160 145,388 121,608 119,245 162,401 170,282 129,965 159,363 238,369 194,043 189,974 120,263 190,872 149,069 124,687 122,264 166,512 174,593 133,255 163,397 244,403 198,955 194,783 123,308 195,704 152,843 127,843 125,359 170,728 179,012 136,629 197,534 250,590 203,991 S H INY A LU MUMIA S E A S T LURA MBI LIK UY A NI IK OLOMA NI K H W IS E RO BUT E RE MAT UNGU MUMIA S W E S T NA VA K H OLO MA LA VA LUGA RI 2013 2014 2015 2016 2017 Graph: Population by Sub-County Source: Kakamega County CIDP
  10. 10. Indicator World National Western Life expectancy at birth (years) 59.7 58.9 48 annual deaths (per 1,000 persons) – Crude mortality 10.54 unknown 12.9 neonatal Mortality rate (per 1,000 births) 26.7 27.8 28 infant Mortality rate (per 1,000 births) 26 52 65 under 5 Mortality rate (per 1,000 births) 29 74 121 Maternal Mortality rate (per 100,000 births) 95 488 880 adult Mortality rate (per 100,000 births) 319 5.8%(F), 339 Crude birth rate (per 1,000 population) 37.4 34.8 38 SITUATION OF HEALTHCARE
  11. 11. Causes and Risk Factors for MORBIDITY Causes and Risk Factors for MORTALITY # Condition Risk Factors # Condition Risk Factors 1 Malaria Exposure to infected vectors 1 Malaria Inappropriate and late medical attention 2 Other diseases of the respiratory system Indoor air pollution 2 Pneumonia Inappropriate and late medical attention 3 Disease of the skins including wounds Childhood & maternal malnutrition 3 Diarrhoea Dehydration 4 Diarrhoea Unsafe water, sanitation &hygiene 4 Anaemia Inappropriate and late medical attention 5 Accidents– fractures, injuries etc Reckless driving and driving under influence 5 abnormal clinical and lab findings Misdiagnosis MORTALITY & MORBIDITY
  12. 12. Type of health facility # Percentage County hospital 1 0.4% Mission/NGO hospitals 9 3.6% Private hospitals 1 0.4% Nursing homes 8 3.6% Public health centres 27 10.8% Private health centres 1 0.4% Public dispensaries 66 26.3% Private dispensaries 31 12.4% Private clinics 107 42.6% Total 251 100% HEALTHCARE INFRASTRUCTURE
  13. 13. • General Staff shortage across all cadres; • 51% of population not within 5km of health facilities; • Basic Equipment in need of maintenance; need for critical inputs like microscopes, weighing scales, etc. • Facilities sparsely located, with inadequate equipment and HR; • Supply of medicines and medical products inconsistent ACCESS TO HEALTH SERVICES
  14. 14. ▪ General Staff shortage across all cadres; ▪ 51% of population not within 5km of health facilities; ▪ Basic Equipment in need of maintenance; need for critical inputs like microscopes, weighing scales, etc. ▪ Facilities sparsely located, with inadequate equipment and HR; ▪ Supply of medicines and medical products inconsistent ACCESS TO HEALTH SERVICES
  15. 15. THE FINDINGS
  16. 16. • Absence of definite government guidelines on proportional allocations to the health sector; • Poorly managed transfer of functions and contested mandates; • Low absorption capacity of county governments; • Poor or weak oversight institutions despite the high level of fiscal autonomy; • Irregular and unpredictable transfers from the national Treasury; • Challenges associated with the performance of IFMIS • Weak citizen participation in the budgeting and planning process, and; • Low capacity for health procurement DEVOLUTION
  17. 17. BUDGETING Quantification& Projections FACILITY Orders Generated SUB COUNTY Rationalization and Filtration COUNTY PHARMACIST Budget Compliance, alignment with essential medicines list, and rationalization of quantities THE LMIS Computation of rationalised orders REQUISITION Generated by the LMIS and signed by the County Procurement Officer, Chief Officer Health, The County Pharmacist, and the Accountant LPO Raised and submitted to KEMSA/MEDS DELIVERY Product Verification PAYMENT CREDIT NOTE In the event of discrepancies with LPO THE PROCUREMENT SYSTEM
  18. 18. Process in accordance with good practice but there are gaps in practice; ▪ Delays in quarterly dispatches leading to stock outs – sometimes of up to six months; ▪ Haphazard increases in number of health facilities – resources stretched thin ▪ Most facilities lack inadequate storage facilities limiting the amount of medicines that can be procured at once. ▪ Low frequency of routine supervision and Spot checks ▪ Weak community participation… although health committees are in place, their usefulness not apparent.
  19. 19. • Based on the County’s expenditure projections, the county health sector would annually require an average of KES 971,796,992 for Pharmaceutical Supplies and KES 95,876,509 for non-pharmaceutical supplies. • In FY 2016/17, the budget deficit on medicines and medical products was 53% which was way higher than the national average deficit of 46.2% • Health budget has increased in absolute terms but decreased as percentage of total county budget - from 25% in FY 2013/14 to 22% to FY 2014/15 • Per capita expenditure on health was $29.7, lower than WHO recommended $34. THE COUNTY HEALTH BUDGET
  20. 20. Health Care Functions 2013/14(KSh) 2014/15(KSh) % Change Capital Formation 1,639,393,838 522,288,487 -68.1% Governance, Health System and Financing Administration 320,813,294 505,987,611 57.7% Inpatient Curative Care 611,789,217 1,258,482,364 105.7% Outpatient Curative Care 1,125,799,841 1,942,550,296 72.5% Pharmaceuticals and Non-pharmaceuticals 261,622,436 289,194,639 10.5% Preventive Care 531,919,312 644,593,230 21.2% Grand Total 4,491,337,937 5,163,096,628 15.0% (THE) BY FUNCTIONS
  21. 21. 0 500 1,000 1,500 2,000 2,500 Capital Formation Governance ,and Health System and Financing Administration Inpatient Curative Care Outpatient Curative Care Pharmaceuticals and Non-pharmaceuticals Preventive Care Millions 2014/15(KSh) 2013/14(KSh)
  22. 22. THE RECOMMENDATIONS
  23. 23. 1. Increase in Budget Allocation to Pharmaceuticals An average deficit of 53% in the quantities of medicines required means even with consistent dispatches to facilities, there would still be rampant instances of stock outs. The county government needs to purpose to progressively reduce this deficit.
  24. 24. 2. Additional Pharmaceutical Personnel There is an inadequacy of pharmacists and pharm- techs yet this is a critical factor in the verification, dispensing and ordering for supplies. While the County government continues to mobilize resources to hire additional personnel, there should be deliberate efforts to conduct CMEs and OJTs for respective staff.
  25. 25. 3. Improvements in the Procurement Process It is possible for the county’s financial structure to consider decentralizing procurement of medicines to the department without losing oversight authority. The other possibility would be to restructure the cycle of procurement from a period of 3 months (quarterly) to 6 months, to attempt to address the delays caused by a long procurement process.
  26. 26. 4. Investment in the Storage Infrastructure For elements a, b and c above to be effective, it is imperative that the county government and partners support the improvement of storage facilities at the sub- county for the start but eventually also for the peripheral facilities.
  27. 27. 5. Strengthen Monitoring & Spot Checks The commodity security technical working group and the County and Sub-County Health management teams need to be supported to conduct regular spot checks and to intensify backstopping to all health facilities. This has been documented to be one of the most effective ways of managing possibilities of pilferage of medicines at facility level. Consider an Information management system for pharmaceuticals
  28. 28. 6. Focusting and Quantification (F&Q) In addition to the budget for epidemiological emergencies, there is need for accurate and regular (annual/bi-annual) medical supply projections to inform timely replenishment of supplies. Accurate projections ensure suitable prioritization, and facilitates evidence based budgeting.
  29. 29. 7. Community Participation There is also need for a grassroots driven Community Health Technical Working Group (CHTWG) to facilitate continuous collaboration between the communities and the county government. This CHTWG can also serve to support the processes by which Facility Management Committees are identified, and subsequently hold them accountable. On its part, the county government should be ready to incorporate the views of the community representatives, and stakeholders in the budgeting process so as to level their expectations and harness their resources.
  30. 30. In suggesting an alternative procurement model, the fundamental questions would often be; what are the gaps in the existing model? What improvements should be made? And who should take what role in the process? With these questions in mind, it is the opinion of this study that the procurement system for pharmaceuticals and non-pharms has gaps that could easily be addressed through a combination of policy level engagements, investments in the supply chain, and intensified involvement of stakeholders (including communities) – subsequently contributing to improvements in the mobilization and management of health resources. IN CONCLUSION…..
  31. 31. Discussions….

In Kenya, County level health systems continue to face challenges that have far reaching effects on citizen’s access to essential health services . Health sector remains a major beneficiary of the national and county budgets, yet there remains critical gaps in the pharmaceutical supply chain which continue to pose significant threats to the access of healthcare services. The purpose of this study was to critically analyse county government procurement procedures (using Kakamega as a case County) with the intent of mapping the direct effect of lapses in procurement systems on the supply and adequacy of pharmaceuticals, and suggest actions that will contribute to improvements in the supply chain.

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