1. Lucy Winkie Mecca, Bpharm U51/63523/2013

2.  About 30% of the world’s population does not to have access to essential medicines.  Kenyan public facilities experience high stock- outs of essential medicines  Financing is an important determinant of access to essential medicines  NHIF Medical Scheme contributes to financing of essential medicines in public hospitals

3.  Effect of introduction of the NHIF-CSDS Medical Scheme on availability of essential medicines not studied.  Introduction of the scheme may paradoxically compromise availability of essential medicines.

4.  Has the funding for essential medicines increased since the introduction of the NHIF- CSDS Medical Scheme?  Did stock-outs of essential medicines reduce after the introduction of NHIF-CSDS Medical Scheme?  What factors affect availability of essential medicines at Webuye District Hospital?

5. To compare availability and funding of essential medicines before and after implementation of NHIF-CSDS Medical Scheme.

6.  To compare the proportion of FIF allocated for procurement of medicines before and after implementation of the scheme.  To determine and compare the contribution of the FIF, KEMSA and others to the essential medicines budget before and after implementation of the scheme.

7.  To determine the frequency and duration of stock-outs of essential medicines before and after implementation of the scheme  To explore factors that could affect the stock- out rate of essential medicines.

9.  A retrospective longitudinal before-after study of four years; the latter two of which the NHIF- CSDS Medical Scheme was in operation.  Study period: 1 Jan. 2010 – 31 Dec. 2013  Study site: Webuye District Hospital, Kenya.  145 essential medicines were selected for study ◦ antiretroviral, anti-tuberculosis and contraceptives not included

10.  Authority to Incur Expenditure records  KEMSA Orders Forms and Invoices  Local Purchase Orders and invoices from suppliers  S3 cards on which all hospital receipts are recorded  Pharmacy summary budgets and stock control cards (electronic and manual)

12.  The median of the quarterly FIF allocation for purchase of medicines was significantly greater after introduction of the new NHIF scheme ◦ Kshs 1.04 million vs. 0.70million, p=0.008  The mean proportion of FIF allocated quarterly for purchase of medicines was also higher ◦ this increase was not statistically significant ◦ 9.12 % vs. 7.55%, p=0.0502

13. Three sources:  KEMSA  FIF  Other Facility Comparisons were made for  Proportion of essential medicine contributed  Expenditure on essential medicines

15. SourceHypothesisp-value KEMSA2012/13 < 2010/110.000 FIF2012/13 > 2010/110.000 Other Facility2012/13 > 2010/110.029

17. SourceHypothesisP value KEMSA2012/13 < 2010/110.000 FIF2012/13 > 2010/110.000 Other Facility2012/13 < 2010/110.122

19.  The average monthly stocked-out time reduced in 2012/13 ◦ this reduction was not statistically significant ◦ 21.75% to 19.47%, p= 0.099  The first months of the quarter were characterized by a high stock-out rate

20.  Some antibiotics such were never stocked out ◦ amoxicillin capsules and co-trimoxazole tablets  Theatre medicines had low stock-out rates (<2.5%) ◦ Neostigmine, Thiopentone, Suxamethonium injections  Some pediatric preparations and topical preparations had high stock-out rates (>50%). ◦ Co-amoxiclav, Erythromycin, Ibuprofen suspension

21.  FIF expenditure was a significant determinant of monthly stock-out rates (p = 0.025)  Supply from KEMSA was a significant determinant of stock-out rates of individual medicines.  Absence from the KEMSA list or non-supply of orders to KEMSA predicted a higher stock-out rate of individual medicines (p < 0.0001)

23.  The increase in FIF allocation can be attributed to additional funding  NHIF and free maternity reimbursements  Decline in KEMSA supply could be attributed to:  reduction in number of essential medicines included in the KEMSA Standard Order Form  challenges from devolution of health services

24.  Financing through FIF and availability in KEMSA were found to be significant predictors of stock-out rates.  No significant change in stock-out rates most likely due to inadequate financing.  The first months of the quarter had the highest stock-out rates due to winding procurement procedures.

25.  No significant change in stock-out rates of essential medicines after implementation of the NHIF-CSDS medical scheme  The NHIF was implemented into a system that was inadequately funded.  Contextual factors should be taken into account when implementing insurance schemes.  Studies on availability of essential medicines after devolution of health should be done

26. Thank you