THE MEDICINES PROCUREMENT PROCESS AND QUALITY STANDARDS AT NMS

THE MEDICINES PROCUREMENT PROCESS AND QUALITY STANDARDS AT NMS By Moses Sserwaga Chronic shortages of medical supplies were the mainstay in many government health facilities in the late 1980s and early 90s largely due to the mismanagement of funds that used to be disbursed to the districts to purchase medicines. The Ministry of Finance used to release funds directly to the districts to procure medicines and other medical supplies for government health facilities. But in many cases the medicines would not be purchased leading to shortages of drugs in hospitals and health centers. The government then took a decision to recentralize the procurement, storage and distribution of medical supplies when it set up the National Medical Stores, (NMS) on December 3rd 1993. Twenty years down the road, there has been remarkable progress in the availability of medicines in all government hospitals and health centers across the country. National Medical Stores (NMS) now procures a range of health commodities (about 2,400 items) using a stock list guided by government health facilities procurement plans. The individual facilities procurement plans are aggregated to form the NMS procurement Plan and subsequently the NMS stock list. The items procured include;Medicines, Hospital Sundries and Consumables, Hospital Equipments, Antiseptics & Disinfectants; Orthopaedic supplies; Laboratory and Diagnostic products, Hospital Stationary, Dental supplies, and Assorted stockless Inventory. National Medical Stores being a government body, procurement is regulated by the Public Procurement and Disposal of Assets Authority (PPDA).National Drug Authority(NDA) as the regulator for the quality of medicines and medical supplies in the country is also a key stakeholder in the procurement process. According to the Head of Procurement at the NMS, Mr. Natamba Alfred Turyahika, most of the medicines and medical supplies are goods in joint demand (e.g. injectable and syringe). NMS therefore puts measures in place to ensure that all the items are available at all times according to the facilities requirements. “Additionally, All the medicines we procure must be appropriately embossed to deter pilferage” he says. NMS has built a wide supplier base to ensure that the required items can easily be sourced to the satisfaction of the health facilities. The supply base consists of local pharmaceutical importers, local manufactures, international suppliers and manufacturers. The suppliers are identified through a rigorous prequalification exercise that is conducted after every three years. NMS has a fully fledged quality Assurance Department .The role of the Quality Assurance Department at NMS, is to work closely with the National Drug Authority to ensure that all medicines and medical supplies that have been manufactured locally or imported in Uganda are highly efficacious (i.e. of good quality), says Ms. Caroline Abalo,the Quality Assurance Officer. Quality Assurance Department is involved in the procurement process right from setting specifications for the items to be procured to the actual evaluation exercise. Ms. Caroline Abalo, the Quality Assurance Officer, said that NMS has strict quality control mechanisms to ensure that only medicines and medical supplies of high quality are purchased and distributed to government facilities for public consumption. Abalo assured Ugandans that NMS does not compromise on the quality of medical supplies it procures for government hospitals. “We take great care and we cannot put the lives of Ugandans in danger. We check and test everything we send out for public consumption we ensure total compliance to local and international set quality assurance standards,” She emphasized. According to the Head of Procurement, a number of innovations have been made to ensure that the requirements of the health facilities are met all the time. These include; • NMS advocated for separate regulations for procurement of medicines and medical supplies. The procurement laws have been amended to include separate regulations for procurement of medicines and medical supplies. This will go a long way in ensuring that procurements are concluded in time and medicines and medical supplies availed to the population • NMS enters into framework contracts for supply of medicines and medical supplies. These allow for quick flexibilities in case of changes in demands for the required items • Expansion of the suppler base to include international manufacturers and suppliers will enable NMS to procure good quality medicines and medical supplies and in the quantities required by NMS to satisfy the health needs of the Ugandan Population As NMS celebrates 20 years of existence, Alfred promises that NMS will continue to efficiently and effectively procure quality and affordable medicines and medical supplies for the Ugandan population and called upon all Ugandans to be vigilant and ensure that drugs and other medical supplies delivered at government hospitals and health centres are not sold to the public. He also appealed to the health workers to ensure that their needs are properly and timely communicated in form of procurement plans to enable NMS avail them in a timely manner. Writer is a communications, media and legal consultant msserwanga@gmail.com

A HISTORICAL PERCEPECTIVE OF UGANDA’S HEALTH SECTOR 1889-TODATE Achievements and setbacks

A HISTORICAL PERCEPECTIVE OF UGANDA’S HEALTH SECTOR 1889-TODATE Achievements and setbacks By Moses Sserwanga The health sector is primarily composed of institutions and resourcesdevoted to the healthcare of the people which include among others provision of safe water, sanitation, adequate food and diet, medical care and access to hospitals and drugs and protection of the environment. It’s important to note that while the period 1986 – 2013 has witnessed fundamental reforms and innovations in the health sector,the period 1889 – 1962 was characterized by the establishment of modern healthcare facilities under the British colonial rule; 1962 – 1970 was post-independence period which saw the consolidation and expansion of healthcare infrastructure and improvement to cater for a growing population, while the 1971 – 1986 period was a bloody scene of civil conflict, mismanagement and destruction of the state infrastructure and the health sector was not spared either . From 1986 to-date there has been marked economic, health sector reforms and innovations to mitigate the anarchy and destruction witnessed as a result of armed rebellions. It’s only recent that peace has been restored to western Uganda following the bloody rebellion of the Allied Democratic Forces (ADF); armed cattle rustling in Teso / Karamoja and Jospeh Kony’s two decades of brutality in northern Uganda. A Historical Health Sector Analysis 1889-1962 Advancedmedical care was first introduced in Uganda in 1889 by the Imperial British East Africa Company (IBEAC), a trading company. The IBEAC brought doctors and nurses to look after its own staff and not for the native population. But owing to successive epidemics of plague, syphilis, sleeping sickness and small-pox, IBEAC was forced to extend medical services to native Africans. These services were eventually taken over by the colonial government. It was the missionaries who started medical services devoted to Africans. Dr Albert Cook opened the first hospital at Mengo in 1897. By 1909, three health centres had been established at Mulago, Mityana and Masaka, devoted to the treatment of venereal diseases (VD), a new epidemic brought to Uganda by Europeans and Indians. Mulago became a hospital for treatment of VDs in 1913, and later a general hospital in 1923. More hospitals and dispensaries were established in provincial and district headquarters throughout Uganda. By 1961, 27 hospitals had been established with over 100 outlying health centres and staffstrength of 1,288 for a population of seven million. Basking in the independence glory 1962-1970 After independence in 1962, twenty-two new hospitals were built bringing the total number in the country to 49 by 1970. The period saw the development of one of the most outstanding networks of health services on the continent. It consisted of hospitals, health centres, a medical school for training doctors, and training schools for nursing, medical assistants and health inspectors. The network of health facilities supported by roads and railways, plus public health nurses and health inspectors ensured easy access to healthcare and improved nutrition, food security, and hygiene. Infant mortality rate (IMR), which is a general indicator of health status of a population, declined from about 350 to 120 per 1000 live births between 1900 and 1970. A period marked with total destruction of health infrastructure 1971 – 1985 After the 1971 military coup which led to political upheavals culminating in three decades of devastating civil wars,the country lost many trained personnel who left the country for personal safety abroad , witnessed decline in economic activity that characterized rising inflation, mismanagement, neglect, and wanton destruction of physical health infrastructure that reduced the hitherto excellent health services to an appalling state by 1975. Public outcry about the deterioration of health services led Idi Amin’s government to institute a commission of inquiry in 1977. But the commission’s recommendations were never implemented. In the meantime, NGOs and church missions continued to increase the intensity and scope of their services, contributing up to 40% of the national health services. The private sector, which was small in 1960s, increased rapidly in response to the gaps left by the deteriorating public health services. The breakdown of law and order, however, made it impossible to enforce statutory controls over private practice. This led to an explosion of illegal private clinics with indiscriminate peddling of drugs by quack medical workers. The painful reforms that turned around an ailing health sector: 1986-2013 When the National Resistance Movement (NRM) assumed power in 1986, it inherited a broken down health system. The new government put in place a Health Policy Review Commission in 1987. The commission came up with a two-pronged strategy: rehabilitation of existing health infrastructure and development of primary Healthcare services. Based on this report, the Ministry of Health prepared a ten-year National Health Plan 1990-2000 outlining 8 critical areas to be addressed namely : recommit to Primary Healthcare; promote community participation through health committees; decentralise health care; promote inter-sectoral collaboration and coordination between ministries, NGOs and donors; promote private practice and its regulation and control; integrate traditional medicine into the national health system; reorganise the health system into first, secondary, tertiary and apex levels; promote alternative methods of financing health starting with user-fees and community financing, and later explore the feasibility for health insurance. Innovations reversed by donor interventions Following the prouncement of the new government’s interventions to revap a sick health sector the donor community expressed concern that that the health budget far exceeded available resources . Donors argued that a much smaller “minimal package of services”should be the basis of the national health plan. The World Bank andother donors thusincreased their involvement in the redefinition of Uganda health sector priorities and in 1992; a three-year plan 1992 -1995 was developed. This health sector framework came up with five policy recommendations which included interalia: • No further expansion of health care infrastructure • Restore the functioning of existing health facilities • Reorient the health system to Primary Healthcare • Use a basic health care package approach based on needs and available resources; and promote user-fees as a way of health financing Around the same time $110m grant was extended to the government of Uganda to deal with the HIV/Aids pandemic (1988 to 2002) to promote awareness, the ABC strategy (Abstain, Be faithful and use Condom) of reducing HIV transmission, and to mitigate social and economic impact of AIDS. The same resources were applied to make anti-retroviral treatment to take off. Under the health system, a few selected hospitals and health centres were renovated but not enough to improve the overall health care. Therefore another loan of $75m was subsequently secured in 1995 to reform the health system. Another reform was decentralisation of health servicesto encourage community participation, promote local self-reliance and accountability, overcome administrative obstacles, and promote coordination. But this reform had down side to it, decentralised administrative units began to be created as rewards for political loyalty and not because they were rationally assessed to be viable for effective health service delivery. The health functions of districts and sub-county local governments far outstripped available resources at their disposal. Health statutory bodies born Several other reforms were undertaken and these saw the establishment of the National Medical Stores (NMS) and National Drug Authority (NDA). While the NDA was created to ensure good quality of medicines and promote rational drug use based on an essential drug list, the NMS was created to procure, store and distribute essential drugs to public sector health facilities. Public-private-partnership (PPP) is one of the recent reforms to be introduced. Based on the belief that the private sector is inherently efficient, and the public sector cannot provide all the services people need, a partnership between the two was to be established and promoted. However, although the policy is not yet fully approved, its implementation has been in progress for at least 15 years with the partnership between the government and missionary health services. The latest reform, since 2005, has been to bring in the for-profit private sector on board. Indeed, small scale partnerships with the private sector have been ongoing. But as yet there are no concrete benefits of such partnerships. The Sector-wide approach (SWAP)SWAP has also since been adopted to address the multiplicity of actors and funding channels in the health sector. It was defined as a partnership among donors, the government and other stakeholders for “a negotiated programme of work”. In Uganda, Swap started in 1999, and by 2005 funding in the health sector had increased substantially. Under the SWAParrangement, achievements were made in national programmes such as immunisation, HIV/AIDS, TB management. Writer is a communications, media and legal consultant msserwanga@gmail.com

UGANDANS ENJOYING BETTER HEALTH SERVICES

UGANDANS ENJOYING BETTER HEALTH SERVICES By Moses Sserwanga The state of a country’s health sector is manifested in the available infrastructure and human resource to cater for the health needs of the people because a healthy and productive population is vital for socio-economic growth and nationaldevelopment. That’s why in its2011-2016 manifesto,the National Resistance Movement (NRM) government led by President YoweriMuseveni promised a number of interventions to turn around Uganda’s health sector. Among the issues the government set out to address was the lack of adequate qualified health workers at both nationalreferral hospitals and local health centers, II, III and IV. The Ministry of Health has since re-allocated an estimated Shs5.7 billion to recruit staff at Health Center IVs. At least 400 graduate health workers have been directly posted to local Government health Units. According to the current Uganda Health Sector Review Report, staffing in public health facilities improved from 58% in 2011/12 to 63% in 2012/13 though still below the recommended target of 70%. The increase in staffing level was a result of thetargeted recruitment for Health Center IVs and IIIs in 2012/13. District level staffing increased from 55% to 60.5%. However, the report indicates that 7,619 of new health workers recruited into the system from Government of Uganda and donor fundsis relatively low due to internal movements i.e. health workersmoving from hospitals to Health Center IVs and IIIs and from one rural district to a more urban district. Hence, the net increase in staffing is not significant. The results of the last health panel survey findings of 2010/11 received in 2013 indicated absenteeismat Health Center II and III level had increased by 2% from 46% in 2009/10 to 48% in 2010/11 instead of adecrease by 20% as per set target. There is need to establish an institutional mechanism foractive monitoring and reporting of health workers absenteeism. Medicines and Medical Supplies available to all government facilities The Health Sector Review Report notes that the National Medical Stores (NMS) continues to supply medicines and health supplies to public health facilities andachieved several of the planned outputs. Notably there was increased access to MaamaKits to82% of mothers delivering in public health facilities. During the financial year 2012-2013, NMS commenced supply ofmedicines and health supplies to all health facilities in the UPDF, Police Force and Prisonservices. The availability of the six tracer medicines (first line antimalarials (ACTs), Depoprovera, Sulphadoxine / Pyrimethamine, measles vaccine, ORS and Cotrimoxazole) in both public andprivate health facilities has continued to improve over the last four years with the percentageof facilities without stock out of any of the 6 tracer medicines increasing from 21% in 2009/10to 48% in 2011/12 and is now 65% in 2012/13. This is a positive trend compared to the recommended target of 60% for 2012/13. Performance of semi-autonomous institutions According to the Review, all the semi-autonomous institutions including; Mulago National Referral Hospital, ButabikaNational Referral Mental Hospital, Regional Referral Hospitals, Uganda Cancer Institute, UgandaHeart Institute and Uganda Blood Transfusion Services showed improvement in provision ofsecondary and tertiary referral services and specialized services and infrastructuredevelopment. The major challenge was inadequate resources (financial and human). Uganda Cancer Institute The Uganda Cancer Institute was able to provide a range of services which included; Outpatients: 12,096 patients; Inpatients: 2,652 patients; Physiotherapy: 2,652 patients andmedical social support: 14,748 patients. The Institute carried out Laboratory: 69,156investigations and Imaging: 9,870 investigations. The Institute achieved almost all of the planned outputs aimed developing the Institute. The 5year strategic plan is being finalized and over 70% of the planned works were completed. Thecancer research coordination structures have been established and the research agenda beingfinalized. Hospital Performance Hospital outputs were assessed using the Standard Unit of Output (SUO). The 14public referral hospitals and fourlarge Private hospitals (Lacor, Nsambya, Mengo and Lubaga) attended to a total of; 2,537,666 Outpatients; 89,626 deliveries and 339,670 admissions among other outputs. On average eachhospital attends to; 140,981 outpatients, conducted 4,979 deliveries and 19,981 admissions. The SUO for these hospitals increased from 5,361,005 in 2011/12 to 8,189,908 in 2012/13. Average staff productivity increased to 2,724 from 1,534 SUO/Staff in 2011/12. Mbale RRH and Masaka hospital had the highest SUOs of 858,116 and 792,551 respectively. The report shows that a total of 110 hospitals offering general hospital services and reporting through the District Health system wereassessed. They collectively attended to a total of; 3,754,144 outpatients; conducted 150,276deliveries and 690,621 admissions among other outputs. On average each hospital attends to;35,080 outpatients, 1,392 deliveries and 6,412 admissions. The total SUO for GHs has increasedfrom 10,506,636 in 2011/12 to 15,129,354 in 2012/13 with notable increase in performance foradmissions, outpatient attendances and deliveries. However, there was a decline in the immunization contacts at the government hosiptals. The 5 top performing hospitals were Iganga, Busolwe, Bwera, Mityana and Pallisa. The Top 5 performing maternal health care facilities In addition to performing Caesarean Sections, 193 Health Center IVs were also assessed using the SUO. In total Health Center IVs attended to 4,473,744 outpatients; conducted 123,610 deliveries; and admitted 395,898 patients. The 5 top performing Health Center IVs in 2012/13 were Bugobero ,Kawempe , Mukono Town Council, Serere and Luwero. Management of HIV/Aids The health sector maintained a positive trend in performance for the HIV/AIDS prevention, care and treatment services. The percentage of children exposed to HIV from their mothers accessing HIV testing within 12 months increased from 32% in 2011/12 to 46% (47,444 children) in 2012/13 . The performance is still below the set target of 55% for the year. There was also remarkableimprovement in the percentage of eligible persons receiving ARV therapy to 76% (total of566,444 of whom 524,603 adults and 41,520 children) from 59% in 2011/12. This achievement was also above the set target (65%) for the year. In FY 2012/13 193,000 new patients were enrolled on the life saving ART against the planned target of 110,000 new patients. This enrolment for the first time exceeded the number of estimated new infections (140,000) over the same period marking a tipping point in the ART programme. This was a result ofstrengthened programs of; accelerated accreditation of health facilities, scale up of Option B+,Web Based ARV Ordering Systems, supply chain rationalization which strengthened the PSMand improved overall support to health facilities by the MoH and Implementing Partners. Impact of government interventions in the health sector The Ministry of Health recommends implementation of the child survival strategy at all levels of care inorder to achieve the Millennium Development Goal four. The review shows that thesector continues providing key interventions like vitamin A supplementation, mass dewormingand health education to sustain improvement of the under-five nutritional status andreductionofanemia. There is need tocontinue community mobilization and involvement in the new community based interventions.Data from the 2011 AIDS Indicator Survey (AIS) revealed an increase in the HIV prevalenceamong adults from 6.4% in 2004/05 to 7.3% in 2011. This trend is attributable to both newinfections and improved survival. Access to a comprehensive rangeof HIV/AIDS care services has been improved through accelerated accreditation of ART siteswhich increased number of health facilities providing ARVs to 1,160 excluding specializedclinics, research programmes and private clinics. A total of 400,000 out of 1,000,000 (40%) Theproportion of pregnant women living with HIV receiving ARVs increased from 50% in 2009 to96% in 2012. There was an increase in the number of malaria patients reported in the outpatients from13,263,620 in 2011/12 to 15,997,210 in 2012/13. Malaria remained the leading cause of morbidity and mortality among all age groups and accounted for 20.6% (5,079/24,651) of allinpatient deaths in 2012/13. The sector improved malaria case management through increasedaccess to medicinesand use of Rapid Diagnostic Tests at HC IIs and IIIs without microscopes. IndoorResidual Spraying was conducted in the 10 target districts for the last 2 years with up to 92%coverage, protecting more than 2.6 million people. There was remarkable reduction of indoorresting vector population reduction as well as remarkable reduction of malaria prevalence intarget districts. Coverage for immunization services showed an increase in the percentage of under oneyear immunized with third dose of pentavalent vaccine (DPT3) from 85% in 2011/12 to 87% (1,319,860 children out of 1,520,347 target, of which 88% were males and 85% females)which is above the HSSIP target (83%) for the year. The DPT3 coverage of 85% in 2012/13 isabove the HSSIP target (83%) for 2012/13. Regarding measles immunization, 85% (1,285,020 children out of 1,520,347 target, of which 86% were males and 83% females) of one year old children were immunized against measles in 2012/13 . Recommendations for better health services The Review recommends that the health sector should focus on interventions geared at improving service delivery at the primarycare level specifically through improving the existing health infrastructure, provision of basicequipment, dissemination of guidelines for standard precautions and infection prevention andcontrol, providing appropriate diagnostic facilities and essential medicines by level of care. Allthis should be augmented with provider training to enhance their knowledge and skills. The Ministry of health needs to carry out further analysis to identify additional factors affecting functionality of HC IVs. KEY FACTS: • National government health budget declined from 8.3% in 2011/12 to 7.4% in 2012/13. • Still below the9.8% target for the year which is also below the Abuja target of 15%. Demographic Information • Demographic Variables Proportion Population • Total Population 100% 35,356,90 • Children below 18 years 56% 19,799,864 • Adolescents and youth (young people) (10 – 24 years) 34.7% 12,268,844 • Orphans (for children below 18 years) 10.9% 3,853,902 • Infants below one year 4.3% 1,520,347 • Children below 5 years 19.5% 6,894,596 • Women of reproductive age (15 – 49 years) 23% 8,132,087 • Expected number of pregnancies 5% 1,767,845 UBOS 2012 Midyear Projection New health facilities to be constructed Staff houses to be built at district hospitals of Moroto,MubendeMiyana, Masindi, Kawolo, Iganga, Anaka,Moyo,Kitgum, Itojo, Kiryandongo, Entebbe, Nebbi, Apac, Nakaseke, Buwenge and, Bukwo. Under World Bank loan hospitals to be upgraded and rehabilitated; Mubende, Moroto Regional referral hospitals and the 17 general hospitals. Installation of solar systems in 156 health centres is under way. The facilities that are benefiting from this programme include; Kibale, Mityana, Mubende, Kabale, Kanungu, Luweero and Rukungiri. Installation is also ongoing in Nakaseke, Kitgum, Apac, Amuru, Kaberamaido, Adjumani and Dokolo. And procurement of ambulances for 27 Health Center IVs, 17 general hospitals and two hospitals is in progress. An ambulatory transport scheme for Kampala is also being worked on. Construction of three general hospitals in Kampala i.eKawempe, Makindye and Rubaga in addition to the newly constructed in Naguru. This will help in the decongestion of Mulago National Referral hospital. A loan of (USD88 million) from the African Development Bank has been approved for the construction of hospitals in Kawempe and Makindye. The writer is a communications, media and legal consultant Based in South Sudan msserwanga@gmail.com

OUR TARGET IS TO HAVE UNIVERSALSUPPLY OF ESSENTIAL MEDICINES

OUR TARGET IS TO HAVE UNIVERSALSUPPLY OF ESSENTIAL MEDICINES SAYS, NATIONAL MEDICAL STORES GENERAL MANAGER (GM)MOSES KAMABARE It has been a long 20 year innovative and progressive journey for the National Medical Stores,(NMS) which was created in 1993 by the National Medical Stores Act to address the gaps in the delivery of medicines and medical supplies which had been experienced under the Central Medical Stores. To reflect on this long journey from scratch to becoming an African model, Moses Sserwanga interviewed Mr. Moses Kamabare the National Medical Stores General Manager. Below are excerpts; Qs:It's 20 years since National Medical Stores was set up in 1993. Can you briefly give use the history of NMS . MK: The National Medical Stores (NMS) was born out of the Central Medical Stores which used to be a department under the Ministry of Health. That department used to be under the Chief Government Pharmacist who apart from taking care of the quality , procurement , storage and distribution of medicines, was also in charge of registration of pharmacists in the country. The Chef Pharmacists was also responsible for policy formulation and as you can see that was a lot ofwork as the demand grew. In 1993 government decided that they take away the functions which were not core to the Ministry of Health headquarters and thus created the National Medical Stores under the National Medical Stores Act of 1993 with the mandate of procurement, storage and distribution of medicines and medical supplies to all government health facilities . The other entities which were created are the National Drug Authority to take care of the quality of medicines and medical supplies and the Pharmacy Council to take charge of professionals i.e the pharmacists and their regulations. The Ministry of Health remained with the core function of resource mobilization, coordination and policy formulation. That’s how NMS came into existence on 3rd December 1993. Qs:What are some of the fundamental reforms that have propelled the rapid transformation of National Medical Stores.In other words what are NMS’ major achievements in the last 20 years ? MK: NMS has been at various levels of discharging it’s mandate under the NMS Act. One of the fundamental reforms we have undertaken is the publication of a national medicines and medical supplies delivery schedule to ensure proper planning and accountability; To ensure that all government hospitals and health facilities at all levels never run out of drugs and other medical supplies throughout the year. We also withdraw from the private sector and concentrated on government health facilities to ensure steady and predictable supply of medicines and medical supplies. The second reform has been the re-centralization of funds for procurement, storage and distribution of medicines and medical supplies at NMS. The third major innovation has been the firm decision to emboss all medicines and medical supplies we deliver to government hospital and health facilities at all levels to stop the wanton pilferage of the medicines. There was a huge problem of stealing government medicines from government health facilities for sale on the open market and left government health facilities without medicines. We have now largely stopped that problem . With embossment of medicines the health workers and the public are put on notice that such medicines and medical supplies are not for sale. The other major reform has been the creation of a new innovative last line delivery system- which is delivering the medicines beyond the District Health Offices up to the individual heath facilities. We have also built a strong management team and staff that is clearly focused on the delivery of the mandate that is given to us. We have rebranded to inform the people we serve about our mission and vision which are; Vision: To have a population with adequate and accessible quality medicines and medical supplies. Mission: To effectively and efficiently supply essential medicines and medical supplies to the public health facilities in Uganda. Qs: What in your view have been the major bottlenecks in distribution of drugs to the Ugandan people? And how have you overcome these bottlenecks? MK: The challenges have been at different levels. First there has been a challenge of having enough qualified health workers to do proper selection and quantification of medicines and medical supplies in time to last them for the duration that is in the published delivery schedule. The second challenge is the health workers at the various health facilities not placing in timely orders to NMS to ensure timely delivery of drugs. The road network which slows down the medicines delivery system is another bottleneck. We have also previously had a big challenge in the procurement processes .Being a government entity we procuremedicines and medical supplies according to the Public Procurement and Disposal of Assets (PPDA) law which didn’t recognize the special nature of medicines procurement. We need more flexibility in the procurement of medicines because at times thereare emergencies. You have to save lives. For the bad roads that’s beyond our control . However, through our seven regional Customer Care offices in Central, Soroti, Gulu, Fort Portal, Mbarara, Hoima and Mbale we are training and reminding the health workers to place their orders in time according to the delivery schedule. We are also planning to open up another regional customer care center in Arua this financial year. We have also proposed to government to amend the PPDA law to cater for the special circumstances in medicines and medical supplies procurement. Parliament has already amended the PPDA Act and put in place special procurement of medicines and medical supplies regulations to fasten the process and ensure timely delivery of medicines and medical supplies to all government health facilities. What remains now is gazetting the regulations. We are determined to eliminate any form of stock outs in government health facilities. Because of the fast procurement processes we are reducing on the lead times in the procurement circle from the previous four-six months to now under two months. With the new regulations, we will be able to get in what we need on emergency within one day. Qs: What do you envisage to be the major challenges going forward and what plans do you have to deal with those challenges? MK : The major challenge going forward is the perception among Ugandans that every illness has a pill to swallow. Many illnesses don’t need medicines. A lot of the medicines people swallow are not necessary .Published literature shows that out of every 100 reported cases in health facilities 75 of them should not be in the health facilities. The 75 cases are presenting conditions which would have been prevented. This means that people are focusing more on cure, rather than prevention of diseases. Why should 100 people report cases of malaria and yet such cases should have been prevented through use of mosquito nets .Why should 100 boda-bodas end up at Mulago causality ward together with their clients and yet they could avoid accidents by behaving responsibly on the roads ,following traffic regulations and wearing helments? Why should 100 mothers be at the risk of dying while trying to bring forth a life when 75 of them shouldn’t be at the health facility only if they had used family planning methods and spaced children. By taking care of our health through preventive measures Uganda would attain the Millennium Development Goal 4 in just two years. Basic hygiene like construction of toilets, vaccination against polio, measles can do quite a lot to better Uganda’s health sector. We need to focus more on prevention than cure. We need to re-program the minds of Ugandans; to engage all of us to deal with the causes rather than the effects of ill health and disease. This calls for a lot of public education and awareness and we need to focus more resources in that direction. Qs.:where do you see NMS in say the next 5-10 years from now? MK: I can see the NMS in a new and bigger home; with big storage space having modern equipment . We need a bigger warehouse to serve the country better. We also plan to set up two big regional warehouses to decongest the center and take our services nearer to the people. We also want to see NMS which is better understood by the people-that we are part of the solution and not a problem . Qs: Are there any key individuals , partners you would like to recognize for standing with you to make National Medical Sources one of the best performing government agencies? MK: I would like to recognize central government and President Museveni who created NMS and has been at the center of all the reforms we have undertaken including the recentralization of funds for medicines and medical supplies. This has reduced on the theft of such funds at the lower levels and led to increased and steady supply of drugs to all government health facilities. We also recognize the political and technical leadership in the Ministry of Health who continuously guide us for better service delivery. DANIDA has been our biggest partner and we are grateful for their support. Others are USAID, CDC, UNFPA, Global Fund, WHO,UNICEF , government agencies like National Drug Authority (NDA), PPDA, Medicines Unit, Auditor General’s office ,civil society; we work with them closely because they ensure that we deliver on our mandate better . Qs:What has inspired you to do this job? MK: There was work to be done and Uganda has given me a lot. I felt obliged to give back to my country; that really inspired me to serve. But above all, I had to serve my God by giving service to His people. When I was outside of NMS I had a feeling that the debate on availability of medicines had been narrowed down to insufficient funding and ignored many other facts of governance and innovation and I felt I would contribute in re-directing the debate. When I see more medicines in government health facilities I believe that contributes to saving life and it makes my stay at NMS worthwhile . Qs.When you sit back and reflect , is there anything you would have done differently. In otherwise ,do you have any regrets? MK: The only regret I have is that the debate about which direction our health system should take should have come much earlier. We went with the flow to concentrate on the supply side which was okay but should have been handled concurrently with the demand side and by now we would have achieved the universal availability of essential medicines and other medical supplies . In other words we must continue in our effort to solve the problem of waste which is largely motivated by corruption,negligence andcommercialization of health services. Take for instance a case where health workers are used to prescribing more than four types of medicines for a simple medical condition/disease yet in other jurisdictions which are better than us, prescription of more than two types of medicines is a rare occurance. This is total waste. Imagine how much medicines is wasted and if utilized rationally it would serve many more people. These are the issues we need to deal with going forward. Qs. what advise do you give to the Ugandan people and the health practitioners about availability of drugs in all health centers across the country? MK: Health workers should improve on the medicines and medical supplies inventory management to ensure proper planning ,make timely orders according to the NMS delivery schedule because its known throughout the year. Health workers should also give rational prescription of medicines to stop wastage . To the general public they should know that the medicines and medical supplies made by government through NMS to all government hospitals and health facilities across the country are not for sale. The medicines are embossed and if seen in the private sector people should report to police or to us here at NMS. Your last word MK: I wish every Ugandan very good health. And whenever you think of medicines and medical supplies in government facilities always remember NMS is your major partner and is part of the solution to get you the medicines you need. ENDS

20 YEARSOF INNOVATION AND TRANSFORMATION AT NATIONAL MEDICAL STORES

20 YEARSOF INNOVATION AND TRANSFORMATION AT NATIONAL MEDICAL STORES Following decades of anarchy characterized with mismanagement of public resources government health facilities were not spared either. Government hospitals and health centers sufferedchronic stock-outs of medicines and medical supplies. The Ugandan people were not only left without drugs but would walk long distances to get whatever little that was left by the thieving bureaucrats.. But 20 years after the introduction of the National Medical Stores (NMS) ,all government hospitals and health centers are not only receiving constant supply of drugs, measures have been put in place to ensure that medicines and medical supplies delivered to are not stolen and sold on the open market. Embossment of all drugs and medical supplies to government health hospitals and health centers IVs, IIIs and IVs, is one of the key innovations that have been undertaken by the leadership of NMS to stop the wanton pilferage of drugs. “ It has come at the displeasure of many but we had to do it to stop the vise of health workers stealing drugs and other medical supplies . All medicines and medical supplies are now embossed with a seal ‘Uganda Government Not For Sale’. The health workers and the general public is accordingly put on notice . If anyone are got selling such embossed drugs they are prosecuted ,” Mr. Moses Kamabare the General Manager of the National Medical Stores says. Embossment of medicines and medical supplies is not only the major innovation that has been undertaken at NMS. The institution has also come up with the Last Mile Delivery system for medicines and medical supplies to ensure that medical supplies reach the end user at all government health facilities across the country. Before this particular innovation,medicines and other medical supplies used to be delivered at the District Health Offices which had no capacity to delivery to the health facilities. This meant that many government health facilities would be without drugs for long periods of time .some drugs would even expire before they were delivered to the health facilities. “The situation was dire and we had to carry out fundamental reforms in our delivery system. So, now we take the medicines and medical supplies direct up to the health facilities . This means all government health facilities can get supplies from NMS in time and account for all the deliveries we make. In order to make the system more user friendly we publish a medicines and medical supplies delivery schedule which is intended to make the delivery of drugs predictable throughout the year .This system does not help in ensuring timely delivery of medicines and other medical supplies but it also ensures effective management of our stock so that health facilities don’t run out of medicines,” Kamabare says. "The situation before the establishment of NMS I must say was s pathetic. There were no medicines to supply and the public largely relied on the private sector for the provision of drugs. But that has since changed. Government is now in position to supply adequate essential medicines to all the hospitals and health centres across the country" Kamabare, explains. In 1993 the then Central Medical Stores (CMS), run by the Chief Pharmacist in the Ministry of Health was responsible for all aspects of medicines. At the time, CMS was the regulatory body in charge of ensuing quality of drugs and licensing of pharmacists among other regulatory functions and also the procurement and distribution of medicines to government health facilities. However, in 1993 the government created the National Medical Stores under the NMS Act of 1993 as an autonomous body to deal with the growing demand for medical supplies in the country while the regulation of medicine quality and premises went to National Drug Authority (NDA). The new law mandated the NMS to procure, store and distribute medicines to all government facilities in the country. "Government medicines are supplied to all government hospitals and all health centres across the country on time and should be given to all in needfree of charge. We now have enough stock of medicines and we are distributing medicines to all government hospitals and health centres on a routine basis against the ordersmade to us by the health facilities. I cannot understand why Ugandans keep being cheated when they go to government hospitals and they have to pay for any medicine given to them. No one should lie to Ugandans that government has no medicines or that there is a government health facility without medicines because of NMS,” Kamabare Says. "The problem of supply of adequate medicines has been solved. All government medicines are embossed and clearly marked "UG" and "NOT FOR SALE”. All that the health facilities have to do is to ensure that they properly quantify their needs,send their orders to NMS in time and ensure that they only prescribe for patients the essential medicines as provided by the Ministry of Health through the Uganda Clinical Guidelines. There are some quarters within government who thought that we could not emboss our medicines. That it was too costly. But we have done it and at zero cost. So any person who tries tosell medicines marked "NOT FOR SALE', even if it’s a health worker, is a criminaland should be arrested immediately and handed over to police,”Kamabare added. Government had originally decentralised the supply of drugs and 70% of the money meant for purchase of medicines was directly being sent to the districts and hospitals. This created problems as it was difficult even for auditors to ascertain that the money was used for the intended purpose. “The money would get 'lost' along the way and health centres and hospitals were left without medicines to give to patients. Even for NMS that had to borrowits working capital from banks and pay interest on it, the resultant mark-up on the medicines to cover our operational costs was upto 35%.Now this mark-up hascome down to 10%.This means that even with no increase in budget for any given health facility, its purchasing power increases by 25%,more than anyincrease any government sector could ever get on its budget! The situation where money for medicines would be sent to health facilities/districts had to be reversed. Now all procurement, storage and distribution of medicines for government health facilities are done by NMS,” he says. With the reforms at NMS, which five years ago had a stock range of 60 items (types of drugs) with a 44% availability rate, it has now grown to register a stock range of 2,400 (different types of medicines and medical supplies at NMS is at 88%) . “And we are targeting 90% availability rate for all the drugs .We need to first demonstrate to Ugandans how much more we can achieve with the resources available to us before we can ask for more. The Ministry of Health together with NMS and other stakeholders have made an innovation of a "Basic Kit". The kit contains the basic medicines which are supplied to all Health CentreIIs and IIIs across the country. The Kit is revised every year tomake it relevant to the people. NMS supplies the kits and other medicines once every month to all government Health CentreIIs and IIIs. Under same innovation the Health Sector Review report for 2012-2013 shows thatnotably, there was increased access to maama kits to82% of mothers delivering in public health facilities. The NMS delivery schedule,is shared with all customers and other stakeholders and delivers all medicines up to the lowest health centres. This system termed as the "Last Mile Delivery" hasreduced on the long delivery times it would take the supplies to move from thedistricts to the health facilities especially in the rural areas. Improved performance Score card • Expanded storage capacity at NMS warehouse in Entebbe which has led to better planning, appropriate procurement and timely distribution of medicines. • Reduced stock-outs of essential medicines and medical supplies at all government health facilities. • Low incidence of expired drugs and other supplies because of procuring only"the suitable" medicines and the use of the 'First Expiry First Out' system. • Timely delivery of medical supplies to health facilities due to a transparent and improved delivery system. • Improved financing. Due to the transparent system, government and other development partners are now able to see better how funds for medicalsupplies are utilised. This has attracted increased financing and confidence in our services. • The image of NMS and that of government facilities is steadily improving regarding medicine availability in public health facilities. • Improved range of medicines and medical supplies from 350 to more than 2400 today. • Introduction of a night shift to take care of increased workload. • Ensuring that all medicines and medical supplies for government health facilitiesare duly embossed. The writer is a communications .media and legal consultant Based in south sudan msserwanga@gmail.com