The 2020 Corona virus pandemic took many of us, if not all, by storm and we are yet to appreciate the extent of change that the pandemic has triggered. In Uganda, like many other countries we have been and still under lock-down leaving the front-line fighters to battle the epidemic. Good news has been coming in that the curve is flattened, and discussion is shifting onto easing the lock-down which implies getting back to work. Prof. Misaki Wayengera in his article “Donald Trump’s undeniable stroke of genius at medicine” in the New Vision of April 30 2020 made a good case for men of different trades to have their take on the Corona virus danger and possible solutions. As a Doctoral student, I am motivated to share what my research could inform discussions on easing lock-down measures instituted in response to the Corona-virus pandemic. The research seeks to explain why stock-out and expiration of medicines occur in Low- and Middle- Income Countries (LMICs).
Supply chain management scholarship and practice has for long acknowledged that supply chains should be resilient (see the evolution of resilience in supply chain management: a retrospective on ensuring supply chain resilience by Pettit, Croxton, and Fiksel of 2019). The concept of resilience could better be understood by relying on a more generally accepted phrase that “the only constant is change”. What distinguishes the survivors from the victims of change is resilience – the capability to withstand vulnerabilities and remain functional under stress and better still emerge stronger than before. Applied to medicine supply chains in LMICs, there is dire need for them to emerge stronger than before primarily because their current source of support has over time turned less comfortable in shouldering the responsibility of providing essential medicines in LMICs. Further, the corona virus pandemic has not spared them necessitating that they would be more calculative on how much they will support the LMICs vis-à-vis rebuild themselves following the pandemic. LMICs therefore need this discussion as we contemplate getting back to work – it may not be business as usual.
I could propose various dimensions of medicines supply chain resilience required in responding to this epidemic, but none stands out prominently as the need to increase government per capita budget allocation for medicines. Here is why and how. Medicines supply chains in LMICs are uniquely challenged being heavily financed by Development Partners and to a large extent operated in form of global purchasing hubs and in country medicines delivery mechanisms set up to deliver medicines to the last mile; often parallel to national medicines management arrangements which perform sub optimally. A report by the Lancet estimated that between $13 and $25 per capita is needed to finance a basic package of 201 essential medicines (Wirtz, et al., 2016). Meanwhile, the last report I have on Uganda estimated per capita expenditure in Uganda to be $1.9. This implies that the balance ($11.1 and $23.1) would have to be covered by the consumers. This direct out of pocket expenditure on medicines by many households brings about inequitable access to medicines as not all households can afford to spend out of pocket.
Last week (ending May 2, 2020), when asked about the situation of supply of health commodities, a District Health Officer responsible for one of the districts in Uganda said that “the amount of money we are allocated for health commodities is insufficient to meet the population that we are supposed to serve. On average our per capita allocation for medicine is about one thousand eight hundred shillings per capita per annum. Less than one dollar per capita to buy more medicines, so the medicines that were sent and that are supposed to last for two months at least before we get the next cycle in most cases take us a month. Then in one month we already start experiencing stockout”
Therefore, there is need for the government to increase budget allocation to Essential Medicines and Health Supplies. Fortunately, Uganda is unique in having a well-functioning country-led public sector agency the National Medical Stores (NMS) to procure, store and distribute medicines as a public good. Additional financing to the agency should prioritize medicines that are still heavily financed by Development Partners including supplies for TB, HIV, Malaria, Reproductive Health and Immunization. This should be considered recognizing that Development Partners may not be able to provide the support we have enjoyed to date.
On the other hand, it is advisable to assume a Total Market Approach (TMA) in stretching available funds to go further. In Uganda, the corona virus epidemic has demonstrated that Government may not afford to provide essential services by relying solely on budget allocation. This has been the logic in restricting food support to “the vulnerable poor” and challenging all who could, not to count themselves as vulnerable poor but find a way to survive the lock-down. This logic is long overdue in the financing of medicines. There are two extremes in the market – zero priced government funded medicines and excessively priced medicines in the private sector. The middle option was dropped – cost sharing (and related policy variants). It may be time to rethink this policy to create an environment for Total Market Approach where the vulnerable poor can receive 100% funding for all their medicine needs while the middle class and wealthy may shoulder 100% of their medicine needs and in between the two extremes we have varying degrees of Government contribution depending on ability to pay. This way we could stretch our meager budget allocation to medicines and related health supplies.
Finally, I hope this becomes part of fodder for those at the front of developing and refining interventions to ease lock-downs and prepare us for the changed work context.