1. Improving Patient Access to Malaria and other Essential Medicines in Zambia Results of a Pilot Project Monique Vledder Jed Friedman Prashant Yadav Mirja Sjoblom

2. Why was the pilot designed? Treatment of malaria lags behind successes in prevention efforts

3. Problem: Drugs are often unavailable in health facilities A 2006 survey shows that ACTs for malaria treatment were not available at time of visit in: – 44% of urban facilities – 29% of rural facilities – 15% of hospitals Stock-outs on district level are less common indicating that distribution from districts to health facilities is the main bottleneck in the system

4. Stockout bottlenecks often lie between the district store and the facility

5. Why is it difficult to deliver drugs?

6. Improving access to essential medicines in Zambia Objective Identify a cost-effective way to improve the availability of drugs through strengthening of the supply chain from MSL to districts and health facilities Approach The pilot compares the effectiveness of two different supply chain interventions to select one (or a combination/variation) that can be rolled-out nationally

7. Two interventions tested System A: Health centers/posts (HCs/HPs) place orders to District Health Officer (DHO) who sends aggregated monthly orders to central stores (MSL) DHOs store commodities and supplies HCs/HPs monthly Districts are responsible for assembling orders for the HCs/HPs and coordinating delivery between the district and HCs/HPs District logistic oversight conducted by new cadre, Commodity Planner (CP) System B: HCs/HPs place orders directly to MSL Orders are packed at MSL in sealed packages for each individual facility Districts only responsible for coordinating delivery or pick up of orders between the district and HCs/HPs, facilitated by CP

8. Pilot evaluation design Districts stratified and randomly selected from 52 peri-urban and rural districts in Zambia Total of 24 districts randomly assigned: 8 districts for system A, 8 districts for system B and 8 comparison districts Pilot implementation for a one-year period Baseline data collected from 250 facilities in Dec-Jan 2008/09 and follow-up data during the same period in 2009/10 Inventory and stock-out rates of tracer drugs measured at both baseline and endline Supplementary information – stocking history, storage conditions – also collected at endline

9. District Selection

10. Reduced stockouts in A system Comparison of baseline and endline values in A districts *the reduction in stockout rate is statistically significant with respect to any observed change in control districts

11. Dramatically reduced stockouts in B system Comparison of baseline and endline values in B districts *the reduction in stockout rate is statistically significant with respect to any observed change in control districts

12. More people get their lifesaving drugs in B districts Number of days of stockouts for the last quarter of 2009

13. Expected impact on malaria mortality If Model B were to be scaled up nationwide, projections indicate: – Reduction of 312,014 uncured cases of malaria and 8,433 severe cases per year – 16,600 U5 deaths due to malaria could be averted by 2015, as well as 2,200 adult deaths – Child and adult mortality due to malaria could be reduced by 21% and 25% respectively – These gains focus only on increased availability of malaria drugs however widespread gains likely from increased availability of all essential drugs

14. Program costs The monthly recurrent costs for Model A is US$2832 per district and for Model B it is US$3325/district. – Pilot was implemented in remote districts with higher transportation costs. – Some net savings in B districts are not included National scale up of B would increase the supply chain operational cost from 4.1 percent to 8.5 percent of the total pharmaceutical budget Total current procurement budget for drugs (partners and MOH): approximately US$100 million/year

15. Model B is 4 times as cost-effective as Model A Cost per day of essential medicine stock-out averted: – Model A reduces stock-out day of one tracer drug at a cost of $14.5 in additional operating costs – Model B achieves the same stock-out reduction at a cost of $4.2 Focusing on possible malaria mortality averted: cost of $22 per YLL averted for a national scale-up of Version B over a 5 year period Compares favorably with many other public health interventions

16. Additional slides

17. System A Commodity Planners Pull system, monthly delivery CP receives stock from MSL and manages district stock in district store room and process and packs orders from health facilities MonthlyTwice Monthly Health facilities receive facility packages from CP Health facilities place orders to CP Medical Stores Limited CP places orders to MSL One pack per districts (for all health facilities) is compiled Districts Health Facilities with adequate storage space Health Facilities with limited storage space

18. System B Commodity Planners + Sealed Packages Pull system, monthly delivery CP receives facility packages from MSL; No stock kept at District Store MonthlyTwice Monthly Health facilities receive facility packages from CP Health facilities place orders directly to MSL Districts Medical Stores Limited One customized pack for each health facility is compiled Health Facilities with limited storage space Health Facilities with adequate storage space