Access to Essential Medicines in the Kenyan Public Health SystemBoston University School of Public Health | Gloabal Health Culminating Experience

Elizabeth Boyer | December 3, 2015

ABSTRACTAs part of upholding the right to health provided in the constitution, Kenya must ensure access to essential medicines. Kenya’s health system includes public, private, and faith-based sectors for health care and medicines, but this analysis focuses on the public sector. The public health sector has made efforts to improve access such as providing medicines free of charge at health centers. Despite these efforts, the Kenyan public health sector continues to face challenges in ensuring access. Challenges include geographic distance patients must travel to reach facilities, frequent stock outs of commonly prescribed medicines, issues in the supply chain, poor storage conditions, and irrational use. All of these challenges are analyzed closely to pinpoint areas for improvement or change. Recommendations, such as providing better trainings in ordering, storing, and prescribing medicines, are provided. Other solutions to supply chain and stock out issues are explored as well. Kenya has the potential and drive to improve access to essential medicines and improve the health its people.

Keywords: Essential medicines, Kenya, supply chain, stock outs, access to medicines

Introduction

The government of Kenya views health as a basic human right. One of the most basic, yet

powerful ways to promote health is through medicines. Kenya still faces high death rates from

diseases that can be easily treated by medicines that should be accessible to every citizen. Public

health facilities often face stock outs of medications. Private and faith-based facilities can very

costly, despite higher availability of medicines. Evidence points to break downs in the supply chain

as one of the major issues in ensuring availability among several others. If Kenya wants to see

improvement in the health of its citizens, actions must be taken to improve access to essential

medicines. The goal of this paper is to analyze the current situation of medicine accessibility in

Kenya, specifically in the public sector, and provide recommendations on policies and actions to be

taken in order to improve access.

Background

Country Background

Kenya is located in eastern sub-Saharan Africa. The World Bank classifies Kenya as a lower-

middle income country. It has a GDP of $60.94 billion in US dollars(1). The country is divided into 8

provinces that have been further divided into 47 newly created counties. These counties were

created under the 2010 Constitution, which initiated the devolution of the country(2). Each county

is an administrative unit, governed by local elected officials. This will be discussed in further detail

below with regards to how it relates to the health system.

The population of Kenya is roughly 44.86 million with approximately 25% living in urban

areas(1,3). The majority of the population is living in rural areas where there is also a high

prevalence of poverty (4). About 42.2% of the population is under the age 15 (3). Kenya has a

maternal mortality rate 400 deaths for every 100,000 live births and the under-five mortality rate

is 71 deaths for every 1,000 live births (3). The life expectancy at birth is 62 years (1). These

indicators all suggest weakness in the Kenyan health system.

The Kenya Health System

The government of Kenya views access to healthcare as a basic right. The Kenya Health

Policy Framework (KHPF 1994-2010) is the overarching health policy which aims to “promote and

improve the health status of all Kenyans through the deliberate restructuring of the health sector to

make all health services more effective, accessible, and affordable” (5,6). The only current available

health policy plan is the second National Health Sector Strategic Plan (NHSSP II 2005-2010). The

third NHSSP is currently under development. The NHSSP sets out specific goals for the health sector

to focus on based on the country’s current needs. The Kenya Essential Package for Health (KEPH),

which is based on a life cycle approach, was first proposed in the NHSSP II 2005-2010 (7). The

system focuses care of different age cohorts through a six level system. These levels are illustrated

in Figure 1.

Figure 1. The Kenya Essential Package for Health (KEPH)

Public health facilities account for 52% of all health facilities, making the government the

leading health provider by a small margin (5). Private, NGO, and faith-based facilities also provide

for a significant portion of the population. In order to encourage more patients to utilize public

health centers and dispensaries, the government of Kenya announced in 2013 the removal of all

users fees at these lower facility levels (8). This includes any medicines given at the visits as well.

Additionally, the government also announced in 2013 that all maternal health services would now

be free. Despite such policy changes, inadequate human resources, infrastructure, and finances

have limited the public sector (4). Such struggles in the pubic sector were witnessed first hand

during my evaluation of level two and three health facilities in Southern Kajiado Sub-County of

Kenya this past summer (9). This causes many patients to continue to turn to the private sector,

despite the higher cost for care and medicines. In some cases, patients even opt out of seeking

professional care at all.

Decentralization

As mentioned before, in 2010 a new constitution was approved for Kenya, which devolved a

wide range of administrative, political, and financial responsibilities to 47 newly created counties

(2). Under this new county system, locally elected administrators and officials were given control of

these selected functions for their county. One such function was the delivery of essential health

services (2). The national government still retains health policy, technical assistance to counties,

and management of national referral health facilities. In addition, the national government is also

responsible for funding the counties based on a standardized formula. The counties must budget

and disseminate these funds.

The County Health Management Team (CHMT) is the responsible unit for budgeting and

disseminating funds to the sub-counties who actively manage health facilities. Complete

management of all public health facilities is the now the responsibility of the county and sub-county

officials. This includes the procurement of medical supplies and medicines. The counties are now in

a critical position for ensuring access to essential medicines at public health facilities. Often times

the funding provided by the national government is not enough to meet the needs of facilities. The

pledged government expenditure on health has not been met over recent years, which reduces the

funds available directly to the counties. In a key informant interview with a nursing officer at a sub-

county hospital in Kenya, finances were stressed as one of the key challenges facing management of

public health facilities. (10)

Essential Medicines

For purposes of clarity, it is important to define essential medicines. The WHO defines

essential medicines as “those that satisfy the priority health care needs of the population” (11).

These medicines are selected with regard to disease prevalence, evidence on efficacy and safety,

and comparative cost-effectiveness. The medicines included in an essential medicine list (EML) are

intended to be available in a health system “at all times in adequate amounts, in the appropriate

dosage forms, with assured quality, and at a price the individual and the community can afford”

(11). The Kenyan government developed their first EML in 2003 but it soon became outdated. The

updated EML was developed in 2010 is still the one currently in use. This list was created with

assistance from a WHO consultant in line with the WHO guidelines (12).

The list is broken into thirty-one therapeutic classes of medicines. There is a core list, which

represent the priority needs for the health-care system. Then there is the complementary list,

presented in italics. These medicines are for priority diseases for which specialized diagnostic or

monitoring facilities and/or specialist medical care, and/or specialist training are needed (12). The

analgesic category of the Kenyan EML is provided in Appendix I as an example of the framework

and how the complementary list is presented. The EML includes information on the lowest level of

care in which the medicine should be used, the therapeutic priority, and the procurement priority

level. The procurement priority is based upon whether the medicine is core or supplementary. Core

“It was a standard to meet health needs but now they are giving bellow par…Facilities like this to operate well, you need money.”—Nursing Officer

list items should always be in stock and available, but the supplementary medicines are only

available upon special request. All of this additional information guides procurement, distribution,

and stock management of the medications. In this regard, the EML provides significant benefits to

the health sector and their management of medicines. It also benefits prescribing by making

training for prescribers more focused because there are fewer medicines to on which they need to

be informed. Fewer medicines enables prescribers to focus knowledge just to medicines on the

EML, enabling them to better identify adverse drug reactions as well. The EML also promotes lower

prices by creating more competition and lowering supplies management costs (12).

Pharmaceutical Sector of Kenya

The last key piece of background information pertains to how the pharmaceutical sector

functions in Kenya. A comprehensive background would be too detailed for this analysis, so I will

focus on the relevant components. The Kenya National Pharmaceutical Policy (KNPP), updated in

2010, is the framework for the pharmaceutical sector (13). Its goal is to provide universal access to

quality pharmaceutical services, essential medicines, and essential health technologies in Kenya (5).

This goal is in fulfillment of the right to health, recognized in the Kenyan constitution.

In order to successfully supply pharmaceuticals within a health system, there needs to be a

strong pharmaceutical sector. Figure 2 was created by MSH as a model for how the management of

the pharmaceutical sector should work (14). Selection was completed with the creation of the

national EML. Procurement, distribution, and use should all be guided by management support.

National policies and laws should then regulate all of these components.

Figure 2. Components of pharmaceutical management cycle

The government of Kenya has a centralized pharmaceutical procurement and distribution

system for essential medicines and medical supplies. The Kenya Medical Supplies Authority

(KEMSA) is the government-owned company responsible for procuring, storing, and distributing

supplies and medicines to the public sector facilities (15). Procurement is limited to medicines on

the EML and any recently updated standard treatment guidelines. Since devolution, KEMSA is now

competing for the business of the 47 counties of Kenya. Each county is now responsible for ordering

and paying for medicines and health commodities for their facilities, rather than the facilities

ordering for themselves. This means that the counties can procure from the company of their

choosing. This has caused KEMSA to adopt a new business model to a competitive medical logistics

authority rather than a bureaucratic medicines supply agency (15). The majority of counties still

choose to use KEMSA for the supply of their medications and supplies, which are delivered

quarterly. Table 1, derived from a 2014 case study on KEMSA, depicts some of the major changes to

KEMSA since devolution (15)

Table 1. Changes in KEMSA’s operating model since devolution

Function Pre devolution model of

KEMSA

Post devolution model of

KEMSA

Who pays? Ministry of Health paid for

the procurement of

commodities and costs of

warehousing and

distribution

Program drugs (HIV/AIDS,

Malaria, TB, RH) financed

separately

Counties will pay the cost of

the commodities plus a

warehousing and

distribution fee

Program drugs (HIV/AIDS,

Malaria, TB, RH) financed

separately

Who procures from

manufacturer/supplier?

KEMSA

Except select program drugs

KEMSA

Except select program drugs

Choice of medicines supply

agency

All public health facilities

receive supplies from

KEMSA

Counties can choose to

purchase from KEMSA ad-

hoc, KEMSA under MOU or

from other suppliers e.g.

MEDS

Which products? Ministry of Health Ministry of Health, KEMSA,

and counties

Who places an order? Health facilities in the pull

system since 2010, MOH

before that

Counties place orders on

behalf of all health facilities

in county

Payment terms Erratic payment from MOH

to KEMSA

Counties pay upfront before

receiving supplies or 30 days

credit

Delivery frequency Quarterly (monthly to

hospitals)

Quarterly (monthly to

hospitals) in most cases. Part

of agreement between

counties and KEMSA

Transport Private transporters

contracted by KEMSA

deliver product to all health

facilities

Private transporters

contracted by KEMSA

deliver product to all health

facilities

Counties may choose to

receive supplies at a single

location

On the patient end, medicines are available free of charge at health centers and dispensaries

in the public sector (level two and three facilities). This is part of the previously mentioned national

policy from 2013 in which all services at these facility levels would be free and without registration

fees, including medicines (8). There is little data on the impact these free medicines on improving

access since the implementation is so recent. The same nursing officer interviewed this past

summer indicated that the reality of the situation is stock outs at these facilities remain an issue

due to delays from KEMSA.

“…some times they [KEMSA] delay. They are not so effective…. They don’t deliver in time.” –Nursing Officer (10)

While access to free medicines in these lower level facilities is a great program, if they are

unavailable or stocked out, it is not helping patients. They will have to seek medications elsewhere.

The private and FBHS facilities provide medicines free for children five years and under.

Waivers are also in place at these facilities for patients who cannot afford medicines. Publicly

procured medicines for priority health programs also are available free of charge. These included

medicines for malaria, HIV/AIDS, TB, and also contraceptives (4). All other medicines in private

pharmacies, private facilities, and at higher level public facilities still require out of pocket payment

and can often be costly, especially for the poorest populations. These are the sources patients are

turning to when they cannot access the free medicines at the clinics and dispensaries. This will be

explored further in the situation analysis.

Situation Analysis

Despite all of the attempts made by the Kenyan government to improve access to medicines

as part of the right to health, there are still many shortcomings. Studies from 2009 to present all

indicate that Kenya still struggles in ensuring the population’s access to essential medicines. When

analyzing access to medicines, geographic accessibility, physical availability, the supply chain,

storage conditions, and rational use are all important aspects to consider. All of these aspects will

be analyzed as we explore the current situation in Kenya with regard to access of essential

medicines. This will help target the problem areas in order to form the recommendations.

Geographic Accessibility

In this paper, geographic accessibility will refer to the distance patients must travel in order

to access essential medicines. In 2009, two surveys were conducted on access to essential

medicines in Kenya (4,5). The first was a household survey and the second was a health facility

survey. These surveys captured data from across the entire country and across all socioeconomic

status (SES) levels. In the household survey, the findings indicated that majority of households are

able to access a public health facility within less than an hour (4). As mentioned in the background,

free medicines are only offered in the public health centers and dispensaries, not any public health

facility. The survey found that less than half of the poor and middle-income households could

access one of these facilities within less than one hour. The great distance patients need to travel to

access the free medicines is notable barrier.

Many patients may not feel the distance is worth traveling for free medicines, especially

since stock outs are known to be an issue. The same household survey found that overall only 32%

of surveyed households responded that the closest public health facility usually had the medicines

they needed. In contrast, the survey also found that 70% of households said the closest private

pharmacy usually has the medicines they need. (4) This discrepancy is why so many patients are

still paying for medicines instead of traveling an hour or more with no guarantee of receiving their

needed medicines. The poorest households may have to use most of their monthly income or even

borrow money in order to obtain these medicines at private pharmacies.

The most frequent source of medicines in surveyed households was from NGO providers. It

can be assumed that many patients are turning to NGO facilities for their medicines. These patients

often travel over an hour to reach these facilities as well, but the higher availability of medicines

incentivizes the great distance. The NGO medicines were also found to be more likely to be kept in a

good container with an appropriate label. The distance remains a barrier, but it appears to be worth

overcoming when availability and quality are assured.

As mentioned in the background, the EML indicates certain medications can only be used at

certain facility levels. Patients who need medications only offered in a hospital face challenges with

geographic distance as well. In order to reach a pubic hospital, 67% of the poorest households and

even 47% of the wealthiest households had to travel over an hour. (4) The travel time to an NGO or

Mission Hospital was similar. These significant distances are of great concern for obstetric

emergencies which only hospitals are equipped with the medicines to treat.

Availability & Stock Outs

Given the low perception of medicine availability at public health facilities in the household

survey, there must be some sort of availability issue at the facility level. Availability refers to

medicines being in stock at the facilities when the patient needs them. In the facility survey from

2009, 15 basic medicines were used as indicators to measure availability. Government run health

facilities had a median of 87% availability of these medications. In contrast, faith-based health

service (FBHS) facilities and private pharmacies both had around 93% availability (5). The

question raised here is why do the government facilities have lower availability of these basic

medicines? The survey also measured availability in the government (KEMSA) warehouse.1 There

was 100% availability of all 15 basic medicines in the KEMSA warehouse (5). This suggests that

there is an issue in the public supply chain and distribution system. This will be more closely

examined in the following section.

1 This survey was conducted prior to the decentralization of medicine procurement to the counties and switch of KEMSA to a competitor rather than the sole source for public facility medications.

This lack of availability of basic medicines has negative consequences on the patients

visiting the public facilities. The survey found that in public facilities, 86% of the prescribed

medications were also dispensed to the patients (5). This means that patients have to seek

medications somewhere else and that could mean paying a substantial amount of money. A patient

may spend a day traveling and visiting a health center and then have to go out and seek some of

their prescribed medicines at a private pharmacy where they must pay out of pocket. This whole

scenario creates dissatisfaction with public health facilities.

The reason medications are unavailable is typically because of stock-outs. Stock-outs can

happen in all sectors, but tend to last longer in public facilities. The national median for stock-out

duration in public facilities in 2009 was 46 days compared to 13.5 in FBHS facilities (5). Masters et

al. conducted a more recent study in 2012, which measured pharmaceutical availability in Kenya,

Ghana, and Uganda. In this study, in Kenya, health centers were stocked-out of 33% of essential

medicines and dispensaries were stocked out of 39% (16). The results indicated that overall, low-

level public health facilities faced the highest proportion of drugs stocked-out. The study found that

the ruralality of the facility did not have a significant effect on stock outs of essential medicines,

however, where the facility received drugs was significantly associated (16). These findings once

again suggest a problem in the supply chain itself and not necessarily with the infrastructure or

distance from main roads.

Moving even closer to the present-day situation in Kenya, in 2014 a study was conducted in

public hospitals in Nakuru County (17). The study measured the availability of essential medicines

but also looked into the most common causes of stock outs. Similar to the other studies, the

researchers found issues with stock outs of essential medicines; primarily antibiotics, anti-malarial

medicines, and analgesics. The study identified four key reasons for the stock-outs: poor

distribution, funding issues, inappropriate selection, and irrational use. Keeping in line with

conclusions drawn from the previously discussed studies, over 90% of the stock outs were

attributed to poor distribution (issues with supply chain). The other three factors, however, were

found as causes for over 50% of the stock outs (17). Many respondents for the survey felt strongly

that they were not allocated enough money from the government to keep essential medicines in

stock. Inappropriate selection and irrational use show issues at the management and policy level.

These factors will be mentioned again in the recommendations section.

Supply Chain

As previously described studies have suggested, there is a need to examine the supply chain.

For the sake of simplifying this analysis, I will just be focusing on the KEMSA supply chain and

storage practices in public facilities. In Kenya there is also MEDS (the faith-based sector warehouse)

and also private manufacturers and distributors. These supply chains also support a large portion

of the population, but evidence from studies indicates greater issues in the public sector, which is

the reason for focusing on it.

KEMSA’s infrastructure consists of two warehouses located in Nairobi and 8 depots

distributed regionally (18). Private transporters contracted by KEMSA make the deliveries to the

facilities. As described in the pharmaceutical sector background, the counties are now responsible

for procuring medicines and commodities for all of their public health facilities. Even though

counties have the option to procure from the source of their choice, most still opt to use KEMSA.

Figure 3 depicts the KEMSA supply chain (18). This process map is a useful visualization of the

various steps in the supply chain, but also can help pinpoint areas in the process where issues could

arise.

Figure 3. KEMSA Supply Chain Process Map

The first point in the supply chain that could contribute to stock outs is the order from the

county officials. The county uses the pull system for ordering medicines. This means each facility is

responsible for reporting their medication needs to the county to be ordered quarterly.

Inappropriate requests are often placed as a result of facility staff who are often untrained in

determining the medication needs of a facility (17). The lack of a threshold for when to order more

of a medication also contributes to inadequate requests. All of these issues at the local level of the

supply chain result in inadequate requests being placed to the county. The county only has these

requests to inform their order to KEMSA.

Funds may also hold up the process if the county has not allocated enough money in their

budget to procure all the needed medicines and commodities for facilities from KEMSA. The process

map shows that KEMSA will not process the order until a payment is made. Those first two steps of

ordering and payment can make a significant impact on the timeliness and adequacy of the supplies

moving through the rest of the chain.

There are other problematic areas in the system. KEMSA only delivers quarterly, which

increases the importance of accurately forecasting needs. Also, if a facility were to run out of a

medicine because of higher demand than usual, they must wait until the next quarter to receive

their shipment. Poor roads and transportation could also contribute to delayed receipt of

medications and commodities at the more rural/hard-to-reach facilities. Central warehouse level

stock-outs also may occur if KEMSA were to underestimate needs when procuring. As you can see,

there are many places in this process where problems could arise, and I have only mentioned a few.

It should also be mentioned, that as nice as the supply chain and KEMSA supply system

looks on paper, it does not always match reality. During a key informant interview with a sub-

county medical director in Kenya, he explained the real situation on the ground in his sub-county.

Despite the way the system is supposed to work, often there are problems. Supplies may be

delivered to the wrong facility or they may not show up when they are supposed to (19). A key

informant interview with the nursing officer of the same sub-county revealed that delays from

KEMSA are very common despite timely ordering (10). Due to the frequency of stock-outs and

delays, sub-county hospitals are provided with an emergency fund to seek out medications when

they run out prior to the next KEMSA shipment. Too often these funds are used up because of these

supply chain issues.

Storage Conditions

It is also important in any discussion of access to medicines to mention storage conditions.

Storage can refer to how medicines are stored in-transit and at the facilities themselves. Proper

storage of medications is imperative to ensure the quality of the active ingredients. One prime

example of the need for proper storage conditions is oxytocin. Oxytocin is an injectable drug used to

prevent and treat post-partum hemorrhage in mothers giving birth. It is included on the essentials

medicine list and is the WHO drug of choice for use during delivery. Oxytocin requires cold storage,

at around 2-8 degrees Celsius. There are often issues maintaining the cold-chain during distribution

of oxytocin. There is a form of oxytocin that can be stored at room temperature (15-30 degrees

Celsius), but hospitals are still required to have the cold storage version of the drug. A study was

done in 2012 of on availability and management of such maternal health medications. The study

found that there was low knowledge of personnel in the public sector of proper storage conditions

for these drugs (14).

Storage conditions are important for all medications as well. The 2009 Health Facility

survey assessed adequacy of storage conditions for medicines. It found that KEMSA warehouses

only met 50% of minimum criteria for adequacy. In public health facilities, the median adequacy

level was 60% for the storerooms and 62% for the dispensing area (5). These are concerning

figures since poor storage can affect the quality of medications. The study also found that many

public facilities were storing expired medications. Not only does this pose the risk of a patient

receiving an expired med, but it also indicates waste and potentially poor ordering. There is a clear

need for interventions to improve the storage of medications.

Rational Use

The final factor affecting accessibility of medicines we will analyze is rational use. What is

rational use of medicines? The WHO provides the following definition: "Patients receive

medications appropriate to their clinical needs, in doses that meet their own individual

requirements, for an adequate period of time, and at the lowest cost to them and their community"

(20). The Ministry of Health has developed National Standard Clinical Guidelines (SCG) and has

recently put out the third edition (17). The purpose of the SCG is to promote rational prescribing

and use of medicines. The issue is weak or nonfunctional mechanisms to ensure compliance to the

SCGs. Rational use of medicines is essential for reduction of waste and hazards to patients in

addition to achieving desired therapeutic outcomes.

In a discussion about improving access to essential medicines, you may be wondering why

rational use is so important. First, if you recall the cycle of pharmaceutical management, the fourth

component of the cycle was “use.” This is because appropriate use determines the availability of

medicines for patients. If wasteful prescribing occurs at a facility, they may run out of the medicine

for when a patient really needs it. Antibiotics are one such class of medicines that are often over-

prescribed and thus prone to stock outs. In Wangu et al., the authors also cited inappropriate use as

a factor contributing to stock outs at public hospitals in Nakuru County (17). Proper use of

medications cannot be overlooked when ensuring the Kenyan population’s access to essential

medicines.

Recommendations

In order to address the issues I have just discussed, I have developed several

recommendations to improve access to essential medicines in Kenya. I have divided my

recommendations into categories that correlate with the five different topics presented in the

situational analysis. Naturally, not all recommendations are high priority and some are intended as

long-term or future goals. Table 2 highlights and summarizes the high priority recommendations.

Geographic Access

Increase number of dispensaries and health centers in rural areas: This

recommendation is low priority and a longer term-goal. The proportion of the population

who are further than one hour travel distance from a public health facility is only 10% (4).

While increasing access to health care and medicine should be a priority of the Ministry of

Health, it is understood that human resources and funding are lacking, which make this

recommendation difficult to implement in the near future.

Improve roads and transportation to facilities: Improving roads and providing public

means of transportation to public health facilities could dramatically increase access to

health care and essential medicines. Similar to the previous recommendation, this is low

priority and a long-term intervention. It requires large amounts of money and an

infrastructure capacity building scheme that is difficult to undertake in Kenya. Despite

challenges, looking into the future, this should be a goal of the Government of Kenya and

Ministry of Health.

Availability & Stock Outs

Provide trainings on proper ordering and improve methods: Since devolution and the

transition of ordering medications for facilities to the county level officials, there have been

issues with stock-outs because of poor anticipation of facility needs. Trainings for

pharmacists, facility staff, and county officials should be provided on how to accurately

quantify the needs of all public facilities in the county. Thresholds should also be set for

each facility level of when a stock is considered low and should be ordered.

Factors such as seasonal health conditions should be factored into the estimation process

for quarterly ordering. Certain drugs may only be needed for certain season, which should

be factored into the process. For example, during malaria season a greater amount of anti-

malarials should be ordered. Outside of this season, only minimum quantities need to be

kept at facilities. This recommendation will not only reduce stock outs of facilities but will

also reduce over-ordering and waste due to expired products.

Encourage Use of LMIS and E-Mobile; ensure capacity for system: In the last couple

years, KEMSA has launched and begun implementing its online portal for ordering

medicines and commodities, the Logistics Management and Information System (LMIS).

This has been created with the purposes of easing the ordering process for the counties,

reducing paper-based forms, and speeding up the process. The manual ordering process

using paper forms could take weeks or months for KEMSA to receive the form. The

turnaround time now has been reduced from an average of four weeks to four days,

depending on the order. LMIS will even send an SMS message when the order has been sent

out so the county officials are informed. It is free of charge to all clients and KEMSA is also

providing free trainings for county health officials. Only three counties have fully embraced

the LMIS so far. More counties should be encouraged to do so. (21)

In addition, counties should ensure capability for using this system. This would mean

equipping facilities with a computer, laptop, or tablet. Internet access also needs to be

ensured. KEMSA has also just created an app to go along with the LMIS system, called

KEMSA E-mobile. This can be used by health facility workers and County Health

Management Teams to report consumption, order medicines, and provide data for

stakeholders. In situations where a computer may not be feasible at a facility, staff can use

any GSM device (even low end phones) to place orders and track past consumption.

Internet access or payment/stipend for phone data would need to be ensure for the mobile

app as well. (22) This is very feasible and has potential to be highly effective in improving

access to medicines by improving availability.

Encourage counties to consider other medicine supply agencies besides KEMSA; look

for quality distribution and lower prices: The counties should embrace the new

competitive market in medicine supply that has appeared as a result of devolution. Many

counties still use KEMSA out of familiarity despite the reputation of poor performance. If a

county continues to make efforts on their end to reduce stock outs and continues to see

issues because of delays from KEMSA, then other medicine suppliers should be considered.

There could potentially be better price options and higher quality service from other

distributors. Additionally, the increased competition will drive down costs in the long run

and motivate KEMSA and other supply agencies to improve the quality of their service.

Supply Chain

Appropriate and timely ordering and payments: This recommendation is very

straightforward and can be high priority since it is a simple solution that can make a big

difference. Counties need to ensure that they are getting their orders and payments to

KEMSA (or other supply agency) in a timely fashion to ensure the facilities receive

medicines before they run out. This is the first step in the supply chain and a delay in this

step can cause a delay the whole process. This requires each facility to accurately quantify

their needs and send it to the sub-county health management team in a timely fashion. The

sub-county officials need to compile all facility orders to send on the county pharmacist.

This pharmacist can only send an order to KEMSA once all orders have been received.

Timely submission by all parties is critical to placing a timely order for the whole county.

The new LMIS and E-Mobile systems will hopefully cut down time by using the internet to

send orders rather than delivering paper forms, which could take days or weeks even. The

trainings recommended previously would also help ensure the orders are accurate in

addition to timely. This is a high priority and highly feasible recommendation.

Promote public-private dialogue and exchange of best practice ideas: This

recommendation has been considered high priority because of the significant impact it

could make on improving the supply chain. Public and private sector supply chains both

have their strengths and weaknesses. KEMSA has a strong and award-winning logistics

management information system (LMIS). The private sector has a far superior distribution

system. If the two sectors could participate in dialogues and exchanges of ideas, each could

benefit from the others strengths to improve the supply chain and access to medicines.

Workshops could be sponsored to bring the two sectors together and discuss ways each can

improve and learn from each other. (18)

Flexibility in KEMSA’s delivery frequency: Currently, KEMSA delivers quarterly with the

exception of hospitals who receive monthly deliveries. Some counties may benefit from

more frequent deliveries, especially since outbreaks and emergency situations cannot be

predicted. Others may wish to remain on a quarterly delivery system. If KEMSA were to

offer flexible deliveries, stock-outs could be reduced and the supply chain would be less

burdened at the beginning of each quarter. KEMSA would also be offering a service that will

increase customer support and aid them in competition for counties’ business. (15)

Storage Conditions

Proper staff at all facilities: Each facility should be staffed with a well-trained pharmacist

or pharmacy technician to manage the stock cards and storage of facility medicines. Since

human resources is a nationwide struggle, this recommendation has been given low priority

since other staff members can receive training on this matter. As a future goal, better

staffing is strongly recommended.

Proper training in storage conditions for medicines: All facility staff, including those

with some sort of pharmacy training, should be required to undergo a training session on

proper storage of medicines. This training should include proper storage of uterotonics

such as oxytocin and ergometrine which need to be stored cold (2-8 degrees Celsius). These

trainings are high priority recommendations since proper storage can have a significant

impact on the quality and potency of many medicines.

Ensure facilities have proper space for storage and dispensing of medicines: In

addition to proper training, all facilities should be evaluated and, if necessary, equipped

with proper space for storage and the dispensing of medicines. This is a low priority

recommendation since the training of staff is a higher priority. This recommendation is still

a measure the MOH should ensure all facilities have to protect the quality of medicines and

ensure the safe dispensing of them.

Rational Use

Staff trainings on Standard Clinical Guidelines (SCGs): The medical staff at each facility

should be trained on the SCGs and each facility should be supplied with a copy of it. This will

promote rational use of medicines. Use of SCGs will also reduce over-prescribing or wrongly

prescribing medications to patients. Better prescribing and use of medicines can also

reduce likelihood of stock-outs of commonly or over-used medicines. This should be a

priority recommendation as it is easy to implement and can have a significant impact on

availability of medicines and patient outcomes.

Medicines Compliance Officer for each county: At the county level, there should be

position for a Medicines Compliance Officer. This individual will be responsible for

monitoring facilities for rational use of medicine and adherence to the SCGs. This individual

will also coordinate the MTCs that were recommended for each hospital previously. This

will provide better accountability for proper management and implementation of best

practices in regards to essential medicines.

Table 2. High priority recommendations/interventions

Recommendation Expected outcomes

Provide trainings on proper ordering and

improve ordering methods

Reduce stock-outs because of appropriate

amounts of medication being ordered and

ordering before stocks get too low

Reduce waste and risk of medication expiration

by minimizing over-ordering of less used drugs

Seasonal conditions are well supplied during

appropriate season and not over supplied during

off-season

Encourage Use of LMIS and E-Mobile;

ensure capacity for system

Reduction in errors and misread forms

More efficient ordering with quicker turnaround

from KEMSA

Better quantification and appropriate stocks;

stock outs reduced

Better tracking of past consumption to better

inform future

More accurate procurement by KEMSA

Promote appropriate and timely

ordering and payment by counties

Reduce delays in medicine deliveries/supply

chain

Encourage counties to consider other

medicine supply agencies besides

KEMSA; look for quality distribution and

lower prices

Encourage competitive market

Reduction of prices

Improved distribution/supply chains

Distributors encouraged to step up quality of

supply chain

Promote public-private dialogue and

exchange of best practice ideas; can be

achieved through sponsored workshops

Private sector can benefit from KEMSA’s award-

winning logistics management information

system (LMIS)

KEMSA can benefit from private sector’s superior

distribution systems

Reduce stock-outs; increase availability of

essential medicines

Quality of medicines maintained in supply chain

Trainings in proper storage of

medications for facility staff

Quality of medicines preserved

Cold medicines (oxytocin) properly stored;

maintain potency

Increase knowledge of proper medicine storage

by all facility staff (not just pharmacists)

Training on use of Standard Clinical

Guidelines (SCG); make SCG available at

all facilities to encourage use by staff

Reduction of irrational use and prescribing

Proper medicines for treatment dispensed to

patients; improved health outcomes for patients

Improved satisfaction by patients

Reduction in stock-outs due to reduction in over-

prescribing commonly stocked-out medicines

Stakeholder Analysis

In order to understand how the recommendations will affect different constituencies, I have

completed a stakeholder analysis. Due to the number of recommendations provided, I have chosen

only to include the high priority recommendations in this analysis. The stakeholders assessed

include patients, public facility staff, private sector distributors, KEMSA officials, county officials,

and government officials. The arguments of each constituent was anticipated and addressed.

Factors such as cost and feasibility were also taken into consideration. Table 3 provides a

comprehensive summary of the stakeholder analysis conducted.

Conclusion

In the 2010 Constitution, Kenya commits to protecting the right to health. Part of

this commitment is ensuring access to essential medicines. The public sector has been

struggling to meet this goal. It has gained a reputation of unreliable availability of

medicines and poor quality due to improper storage. Despite free medicines at lower level

facilities, many patients continue to choose other sources because of such poor

perceptions. The recommendations in this paper aim to increase access to quality essential

medicines in Kenya’s public facilities by strengthening the supply chain, reducing stock

outs, improving storage conditions, and encouraging rational use. When patients can access

medicines, unnecessary deaths are prevented and lives are improved. Kenya has great

potential to do just that and improve the quality of its health system by ensuring every

citizen has access to essential medicines.

Table 3. Stakeholder Analysis

STAKEHOLDER

Provide trainings on proper ordering and improve ordering methods

Encourage Use of LMIS and E-Mobile; ensure capacity for system

Promote timely ordering and payment by counties

Encourage counties to consider other medicine supply agencies besides KEMSA

Promote public-private dialogue and exchange of best practice ideas

Trainings in proper storage of medications for facility staff

Training on use of Standard Clinical Guidelines (SCG)

Patients Support ALL: The patients in Kenya would support all six of the priority recommendations. The reason for the support is because all recommendations would improve availability to essential medicines, require no cost tot hem, and also improve over all quality of medications and treatment provided to the patients. They would likely have increase satisfaction with the public health system

Public Facility Staff

Support: Increased knowledge on how to order medicines, reduces stock outs, increases availability of meds for patients

Support: Makes ordering easier, reduces paperwork, decreases delays

Mixed: this would reduce delays and stock outs, but with their current work load and understaffing, staff may find this challenging

Mixed: Wants to ensure reliable supply of quality medicines from any source, but is familiar with KEMSA already

Support: Would improve system; can benefit from exchange; will help improve medicine availability in long run

Support: will increase their knowledge and skills; will ensure medicines retain quality and treat patients

Support: will increase their expertise and knowledge in prescribing, will also make prescribing more simple; will result in better patient outcomes when treated properly; reduce stock outs from not over-using certain meds

Private Sector Distributors

Support: More accurate orders will be placed; assists in accurate

Oppose: This system makes KEMSA more appealing,

N/A Support: Would provide opportunity to compete for

Mixed: The private sector may be hesitant to work with their

Support: distributed medicines will retain their

Support: medicines will be rationally prescribed and

procurement calculations

drawing away potential clients

more business and increase client base

competitor, but will acknowledge they can reap great benefits from these exchanges as well as foster better relationships with potential clients (county governments)

quality; reduce waste of medicines improperly stored and no longer potent

will have better patient outcomes; will reduce stock outs and improve perception of distributor

KEMSA Support: More accurate orders will be placed; assists in accurate procurement calculations

Support: They developed this tool themselves; draws in more customer; increases their efficiency, allows them to make better procurement estimates

Support: orders would reach KEMSA in timely manner so they can then be distributed in timely manner as well; keeps system running smoothly

Oppose: This would be taking customers away and reducing their business

Mixed: KEMSA will also be hesitant about working with a competitor and sharing their ideas, but they can reap many benefits from the exchange as well that will improve the efficiency of their system

Support: medicines delivered will remain active and help patient; improves satisfaction with KEMSA when medicines “work”; reduce waste of ruined drugs

Support: medicines will be rationally prescribed and will have better patient outcomes; will reduce stock outs and improve perception of KEMSA

County Officials Support: orders placed are more accurate; more accurate consumption records; less stock outs; more patients accessing medicines; sufficient medicines during seasonal outbreaks

Support: Makes ordering easier, reduces paperwork, reduces wait time and delays, increases accuracy of orders, better coordinates all facilities in county

Mixed: Similar to the staff, this would reduce delays and allow them to get in orders to KEMSA in time to get order before stock outs; staff and workload constraints may make this

Mixed: Wants to ensure reliable supply of quality medicines for the best prices from whatever source that may be, but is already familiar with KEMSA and the ordering system

Support: Collaboration and exchange between the two sectors will serve to strengthen both, increasing the efficiency and quality of medicine and commodity supply; as both improve, competition may

Support: Medications that county purchased will retain their potency and effectiveness; better patient outcomes; better access to effective medicines; more

Support: Medications that county purchased will be rationally used; reduced stock outs from over-use of certain medications; better patient outcomes as a

recommendation seem like added pressure; LMIS should assist

increase and prices may in turn decrease

knowledgeable staff

result of proper prescribing

Government Officials

Support: reduction of stock outs, increased availability of medicines; more efficient system

Support: Strengthens the public health system by making public supply chain more efficient; increase medicine accessibility

Support: Would reduce delays and stock outs; overall availability of medicines would increase; system will be more efficient

Mixed: Wants to support KEMSA & public sector; in support of any method to lower costs spent of medicines

Support: Both sectors can benefit from each others strengths; this will improve access to medicines in both sectors improving the health of the population as a whole

Support: more knowledgeable health workforce; government funded medicines retain their potency and effectiveness; better patient outcomes, increased population health

Support: Increased rational use of EML medicines; reduced stock outs from over use of certain meds; better patient outcomes and improved population health from appropriate prescribing

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http://www.who.int/medicines/services/essmedicines_def/en/

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Appendices

Appendix I. Sample of Kenya’s 2010 EML

Acronym/Coding Key: LOU (Level of Use): Level 1-6 based on KEPH Classification. The level indicated against each medicine represents the lowest level where the medicine is expected to be distributed, prescribed, and dispensed. VEN (Therapeutic Priority): V=vital, E=essential, N=non-essentialAB(Procurement Priority):

A= Core List: routine items which should be always stocked & availableB= Supplementary List: non-routine items, not routinely stocked and only available upon special request through the established requisition process

# Drug Dose-form Size/ Strength

LOU VEN AB

2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES (NSAIMs), MEDICINES USED TO TREAT GOUT, AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARTDs)2.1 Non-Opioids and Non-Steroidal Anti-Inflammatory Medicines (NSAIMs)2.1.1 Aspirin Tablet 300mg 1 V A2.1.2 Diclofenac a) Injection* 25mg/ml in

3ml ampoule

4 V A

*for restricted use only in sickle-cell crisis & severe pain in patients who cannot swallowb) Suppository 100mg 4 E A

2.1.3 Ibuprofen a) Oral liquid 100mg/5ml 2 V Ab) Tablet 200mg 1 V A

2.1.4 Paracetamol a) Oral liquid 125mg/5ml 1 V Ab) Suppository 60mg 2 E Bc) Suppository 125mg 2 E Bd) Tablet 500mg 1 V A

2.2 Opioid Analgesics2.2.1 Codeine Tablet 30mg

(phosph.)4 E A

2.2.2 Morphine a) Injection 10mg/ml (HCl or sulphate) in 1 ml ampoule

4 V A

b) Oral liquid 10mg/5ml (sulphate)

4 V A

c) Tablet, 60mg 4 V A

prolonged release (PR)

(sulphate)

2.3 Medicines Used to Treat Gout2.3.1 Allopurinol Tablet 100mg 4 E A2.4 Disease Modifying Agents Used in Rheumatoid Disorders (DMARDs)2.4.1 Methotrexat

eTablet 2.5mg

(sodium salt)

4 E A

Complementary List2.4.2 Azathioprine Tablet 50mg 4 E A2.4.3 Chloroquine Tablet 150mg

(phosphate or sulphate)

4 E A

2.4.4 Sulfasalazine Tablet 500mg 4 E A