Improving Patient Access

to Malaria and other

Essential Medicines in

Zambia

Results of a Pilot Project

Monique VledderJed Friedman

Prashant YadavMirja Sjoblom

Why was the pilot designed?Treatment of malaria lags behind successes in prevention efforts

% of children <5yrs slept under ITN last

night

% househols sprayed previous

12 months

% mothers who took 2+ doses of

IPT

0%

10%

20%

30%

40%

50%

60%

70%

24% 26%

59%

41% 43%

66%

MIS 2006

MIS 2008

% children took antimalarial within 24h

% children took Coartem within 24h

0%

10%

20%

30%

40%

50%

60%

70%

32%

6%

29%

8%

MIS 2006

MIS 2008

Problem: Drugs are often unavailable in health facilities

• A 2006 survey shows that ACTs for malaria treatment were not available at time of visit in:– 44% of urban facilities– 29% of rural facilities– 15% of hospitals

• Stock-outs on district level are less common indicating that distribution from districts to health facilities is the main bottleneck in the system

Stockout bottlenecks often lie between the district store and the facility

ACT Pediatric (malaria treatment)

ACT Adult (malaria treatment)

Amoxicillin (Antibiotics)

CTX (Antibiotics)

DepoProvera (Contraceptive)

SP (malaria prevention)

0% 10% 20% 30% 40% 50% 60%

DHOHealth Facility

Why is it difficult to deliver drugs?

Improving access to essential medicines in Zambia

ObjectiveIdentify a cost-effective way to improve the availability of drugs

through strengthening of the supply chain from MSL to districts and health facilities

ApproachThe pilot compares the effectiveness of two different supply chain

interventions to select one (or a combination/variation) that can be rolled-out nationally

Two interventions testedSystem A: • Health centers/posts (HCs/HPs) place orders to District Health Officer

(DHO) who sends aggregated monthly orders to central stores (MSL)• DHOs store commodities and supplies HCs/HPs monthly• Districts are responsible for assembling orders for the HCs/HPs and

coordinating delivery between the district and HCs/HPs• District logistic oversight conducted by new cadre, Commodity Planner

(CP)

System B: • HCs/HPs place orders directly to MSL• Orders are packed at MSL in sealed packages for each individual facility• Districts only responsible for coordinating delivery or pick up of orders

between the district and HCs/HPs, facilitated by CP

Pilot evaluation design

• Districts stratified and randomly selected from 52 peri-urban and rural districts in Zambia

• Total of 24 districts randomly assigned: 8 districts for system A, 8 districts for system B and 8 comparison districts

• Pilot implementation for a one-year period• Baseline data collected from 250 facilities in Dec-Jan 2008/09

and follow-up data during the same period in 2009/10• Inventory and stock-out rates of tracer drugs measured at

both baseline and endline• Supplementary information – stocking history, storage

conditions – also collected at endline

District Selection

Reduced stockoutsin A system

Comparison of baseline and endline values in A districts

*the reduction in stockout rate is statistically significant with respect to any observed change in control districts

ACT Pediatric (malaria treatment)

ACT Adult* (malaria treatment)

Amoxicillin (Antibiotics)

CTX* (Antibiotics)

DepoProvera* (Contraceptive)

SP (malaria prevention)

0% 10% 20% 30% 40% 50% 60% 70% 80%

A baselineA endline

Dramatically reduced stockouts in B system

Comparison of baseline and endline values in B districts

*the reduction in stockout rate is statistically significant with respect to any observed change in control districts

ACT Pediatric* (malaria treatment)

ACT Adult* (malaria treatment)

Amoxicillin* (Antibiotics)

CTX* (Antibiotics)

DepoProvera* (Contraceptive)

SP* (malaria prevention)

0% 10% 20% 30% 40% 50% 60% 70% 80%

B baselineB endline

More people get their lifesaving drugs in B districtsNumber of days of stockouts for the last quarter of 2009

ACT Ped

iatric

(mala

ria tr

eatm

ent)

ACT Adult (

malaria

trea

tmen

t)

Amoxicilli

n (Antibiotics)

CTX (A

ntibiotics)

DepoPro

vera

(Contracep

tive)

SP (m

alaria

preven

tion)0

5

10

15

20

25

30

35

40

comparison districtsA districtsB districts

Expected impact on malaria mortality

If Model B were to be scaled up nationwide, projections indicate: –Reduction of 312,014 uncured cases of malaria and 8,433 severe cases per year–16,600 U5 deaths due to malaria could be averted by 2015, as well as 2,200 adult deaths–Child and adult mortality due to malaria could be reduced by 21% and 25% respectively–These gains focus only on increased availability of malaria drugs however widespread gains likely from increased availability of all essential drugs

Program costs• The monthly recurrent costs for Model A is US$2832 per

district and for Model B it is US$3325/district.– Pilot was implemented in remote districts with higher

transportation costs. – Some net savings in B districts are not included

• National scale up of B would increase the supply chain operational cost from 4.1 percent to 8.5 percent of the total pharmaceutical budget

• Total current procurement budget for drugs (partners and MOH): approximately US$100 million/year

Model B is 4 times as cost-effective as Model A

• Cost per day of essential medicine stock-out averted: – Model A reduces stock-out day of one tracer drug at a cost

of $14.5 in additional operating costs– Model B achieves the same stock-out reduction at a cost of

$4.2• Focusing on possible malaria mortality averted: cost of $22

per YLL averted for a national scale-up of Version B over a 5 year period

• Compares favorably with many other public health interventions

Additional slides

System ACommodity Planners

•Pull system, monthly delivery

•CP receives stock from MSL and manages district stock in district store room and process and packs orders from health facilities

•Monthly •Twice Monthly

•Health facilities receive facility packages from CP

•Health facilities place orders to CP

• Medical Stores Limited

•CP places orders •to MSL

• One pack per districts (for all health facilities) is compiled

• Districts

•Health Facilities • with adequate storage

space

•Health Facilities • with limited storage

space

System BCommodity Planners + Sealed Packages

•Pull system, monthly delivery

•CP receives facility packages from MSL; •No stock kept at District Store

•Monthly •Twice Monthly

•Health facilities receive facility packages from CP

•Health facilities place orders directly to MSL • Districts

• Medical Stores Limited

•One customized pack for each health facility is compiled

• Health Facilities •with limited storage space

• Health Facilities • with adequate storage

space