1. Stop the Stock-outs! Civil Society approaches to monitoring PSM for essential medicines Christa Cepuch BSc Phm Health Action International (HAI) Africa Strengthening Governance in Pharmaceutical Procurement WBI meeting: 12 April 2011, Stanley Hotel, Nairobi

2. Outline  Collaborative monitoring of medicine prices and availability (MMePA)  Stop the Stock-outs: civil society access campaign  Pill Check Week  monitoring budgetary allocations for essential medicines  Other efforts by civil society  citizen’s report card  Indian civil society monitoring of PSM

3. WHO: Availability of essential medicines Average availability was only 34.9% in the public sector and 63.2% in the private sector. Public sector availability of medicines is consistently lower than in the private sector.

4. Kenya MMePA: summary of findings (2004 – 2009)  Over time, the public sector has provided more and more medicines free of charge (or for a flat fee)  Prices are higher in private sector vs FBHS (+ 10 – 20%) and vs public sector (+ 50 – 150%)  Medicines are less consistently available in the public and FBHS sectors – availability has slightly decreased over time – shorter lists (e.g. less medicines) are “more available” than longer lists: corroborated in L2 facility survey (2008)

5. MMePA Kenya: results across entire basket of medicines surveyed ( not valid )

6. MMePA Kenya: availability of amodiaquine and AL over time

7. MMePA Kenya: availability and price of insulin over time (1)

8. MMePA Kenya: availability and price of insulin over time (2)

9. MMePA Kenya: availability and price of reproductive health medicines over time

10. Using evidence for advocacy: Stop Stock-outs (SSO) Campaign  Work with partners in different countries to engage the public on their Human Right to access essential medicines  KETAM, CIN, EPN, KEHPCA, AGHA, NAPHOFANU, HEPS, ZLP+, TLAC, MHEN, others

11. SSO Campaign: context and structure  30 years after the introduction of the EM concept, there are simply not enough medicines on the pharmacy shelves  Stock-outs are worst in rural areas, and harm poor people  Stock-outs force people to purchase medicines from much higher suppliers in the private sector or -- more frequently - - simply to go without needed medicines  The failure to properly stock public health pharmacies and clinics stems in part from economic constraints and bureaucratic obstacles. But above all, it is a failure of political will. If governments commit to get EMs on the shelves, they can do it.  CS teams in five countries (Malawi, Ke, Ug, Zam, Zim)

12. SSO Campaign: demands The SSO campaign is calling on governments and health departments to end stock-outs now by: Giving financial and operational autonomy to the national medicines procurement and supply agency Allowing representation of civil society on the board of the national medicines procurement and supply agency Ending corruption in the medicine supply chain to stop theft and diversion of essential medicines (EMs) Providing a dedicated budget line for EMs Living up to commitments to spend 15% of national budgets on health care Providing EMs for free at all public health institutions

13. SSO Campaign: community-based monitoring via “pill check week”

14. WHO: Public expenditure on medicines There is wide variation in national per capita spending on medicines by the public sector, ranging from US $0.04 to $187.30 among developing countries.

15. Availability of Artemether/lumefantrine 20/120 mg in Kenya Global Fund grant start date (02/2006) WHO / HAI Africa: Increased finances and differential pricing -- impact on availability

16. Kenya budget monitoring: government allocations to health and trends

17. Kenya budget monitoring: percent of MOH recurrent budget to EMMS 2005/062006/072007/082008/092009/102010/11 10.511.111.612.110.358.87

18. Kenya budget monitoring: per capita spending on EMs CountryPer capita expenditure (USD) Botswana25 Rwanda0.4 Tanzania0.96 Zambia3.54 Namibia4.3 Kenya1.37 Ethiopia1.26 Eritrea2.6

19. Kenya budget monitoring: key findings Essential Medicines are highly under-funded: per capita spending USD 1.37 (2010 / 11) Share of health budget that goes to EMMS is relatively low when compared to other countries: below 10% in 2010 / 11 Financing of pharmaceuticals through the “off-budget” Substantial out-of-pocket spending for medicines

20. Other efforts by civil society  Citizen’s “report card” based on KEMSA assessments: status of implementation of recommendations  Indian civil society monitoring of PSM