Edmondo Aimee PHA Final Spring 2014

INNOVATIONS IN ACCESS TO ESSENTIAL MEDICINES: FOCUS ON SOUTH AFRICA 1

T u l a n e U n i v e r s i t y S c h o o l o f P u b l i c H e a l t h a n d T r o p i c a l M e d i c i n e

Innovations in Access to Essential Medicines: Focus on South Africa Aimee Edmondo MPH Candidate

Spring

2014

08 Fall

Public Health Analysis Culminating Experience

Department: Global Health Systems and Development Focus: Program Design and Implementation Advisor: Nathan Morrow

List of Acronyms ANC – African National Congress ARV – Anti Retro Virals CHW – Community Health Worker DoH – Department of Health EDL – Essential Drugs List EDP – Essential Drugs Programme eHealth – Electronic Health Informatics EML – Essential Medicines List EMR – Electronic Medical Records FDC – Fixed Dose Combination HIS – Health Information System HIM – Health Information for Management HIV – Human Immunodeficiency Virus HST – Health Systems Trust ICT – Information and Communications Technology iDART – Intelligent Dispensing of Anti-‐Retroviral Treatment KEMSA – Kenya Medical Supplies Agency LMIC – Low and Middle-‐Income Countries LMIS – Logistics Management Information System MatCH – Maternal Adolescent and Child Health mHealth – Mobile health technology MSF – Medecins Sans Frontieres / Doctors Without Borders MSH – Management Sciences for Health NCD – Non-‐Communicable Disease NDP – National Drug Policy NDoH – National Department of Health NGO – Non-‐governmental Organization PHC – Primary Health Care PTC – Pharmacy and Therapeutics Committee RCT – Randomized Controlled Trial SMS – Short Message Service SSA – Sub Saharan Africa STG – Standard Treatment Guidelines TB – Tuberculosis WHO – World Health Organization


Abstract South Africa instituted no cost public healthcare services in 1994, despite this, South Africa suffers from

a quadruple health burden, which includes communicable disease, non-‐communicable disease, poor

maternal and child health, and injury and death due to violence. Additionally, South Africa is home to

the largest populations of HIV and TB infected individuals in the world. Satisfactory health outcomes are

dependent upon reliable access to health care and uninterrupted supplies of essential medicines.

Recently, advocacy organizations have reported regular stock outs of essential medicines, and reviews

of patient experiences in the public healthcare delivery system indicate that patients are required to

repeatedly return to health facilities to collect medications. Consequently, impoverished patients are

often demoralized and experience catastrophic out of pocket expenses. In this analysis mobile

technology is explored as a potential intervention to empower patients and simultaneously improve

access to essential medicines in South Africa.

A qualitative review of literature from the last decade was conducted to explore essential drugs access

and the pharmaceutical supply chain management system in South Africa. Additionally, mobile health

technology interventions in sub Saharan Africa were reviewed for their feasibility and potential to

improve supply chains. Policy documents and reports from advocacy organizations were also used to

inform this analysis.

Over 20 documents were identified for this public health analysis. Findings related to access to

medicines and care, pharmaceutical supply chain systems, and the role of mobile health technology

indicate that little comprehensive research has been conducted in South Africa on these topics and the

relationships between them. Furthermore, few peer-‐reviewed studies have explored the impact of

healthcare access barriers and essential medicine shortages in South Africa on treatment adherence or

overall health outcomes.

Widespread mobile phone use, advanced ICT systems, and government-‐initiated health technology

policies suggest that South Africa has an enabling environment to facilitate the implementation mHealth

to improve essential medicines access. It should be noted, however, that limited stewardship, poor

leadership, resource constraints, and an ineffective culture of service delivery will need to be


ameliorated in order to implement beneficial mHealth innovations to improve pharmaceutical supply

chain management.

Background

WHO and the Model List of Essential Medicines

In 1975 global concerns about the availability of important lifesaving medicines in the public sector,

particularly in developing countries, led to a request by the World Health Assembly for the World Health

Organization (WHO) to establish a model list of essential medicines. The first essential medicines list

(EML) was released in 1977. Challenges to the EML and changing patterns of health and evidenced-‐

based practices have led to several revisions of this list (Laing et al. 2003). Today, the WHO EML is in its

18th edition. Essential medicines are defined by WHO as:

“Those drugs that satisfy the priority health care needs of the of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-‐effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, appropriate dosage forms, with assured quality and adequate information, and at a price the individual and community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility (2002).”

Accordingly, South Africa also has its own essential drugs list (EDL) and associated treatment guidelines,

though the evolution of this list has been fraught with controversy and heavily influenced by a host of

growing epidemics such as HIV and TB (Laing et al. 2003).

Primary Health Care and the Essential Drugs List in South Africa

Following democratic transition in South Africa in 1994, the African National Congress (ANC) proposed a

plan for national health services based on the concept of primary health care (PHC) promoted at Alma

Ata. Through this plan, the National Department of Health (NDoH) sought to address the unequal

distribution of health services, infrastructure, monetary, and human resources resulting from Apartheid.

No cost PHC became available to the public though a district health system following the construction

and upgrading of over 1,500 clinics (Coovadia et al. 2009). In 1996 South Africa released the National

Drug Policy (NDP), which outlined changes in drug management and detailed a host of legislative and

regulatory priorities. One of these priorities involved the establishment of a representative committee


to produce standard treatment guidelines (STGs) from which the medicines to be included in the PHC

EDL would be extracted. The first editions of these documents were released in April of 1996 (Gray &

Suleman 2000, Essack et al. 2011).

Though the national PHC EDL and STGs are regularly reviewed and updated, limited political will, patent

policies, and inequitable resources mean that some essential drugs are less accessible than others. HIV

has been a prominent issue in the EDL process. Today there are clear STGs for HIV and TB and policy-‐

based strategic plans at the national and provincial level in South Africa, but at one time anti-‐retrovirals

(ARVs) were considered too expensive for public use. For example, in the 1998 PHC EDL it is noted that

“these medicines are very costly and cannot be provided on a mass scale by the public health services…

they may only be provided on a limited and selected basis or for academic and research purposes only”

(Laing et al. 2003). Fortunately, the World Health Assembly approved a Revised Drug Strategy in May of

1999, which allows for interpretation of the World Trade Organization (WTO) TRIPS agreement based on

priority global health concerns (Hoen et al. 2011). This has greatly reduced the cost of ARVs and allowed

South Africa to establish a national ARV program in 2003 with assistance from foreign donors. With

over 2.1 million people initiating ARV treatment in South Africa in 2012, it is the largest program of its

kind.

Health Service Delivery and the Health Status of South Africa

Multiple reviews on the process of implementing post-‐Apartheid national health services in South Africa

have indicated that progress is slow, uneven, and faces multiple difficulties. (Gray & Suleman 2000,

Coovadia et al. 2009, Levitt N, 2011). Major setbacks in implementation have included confusion about

responsibilities within the district health system. In the 2004 National Health Act, the NDoH is identified

as the sole responsible party for national health policy, while public health service delivery was deemed

a provincial responsibility. Within the national pharmaceutical program, NDoH is responsible for the

tender process, while provincial governments are responsible for ordering, storage, and distribution of

medicines. Additional national health care challenges include skilled human resource shortages,

unequal distribution of resources – with very few at the rural community or primary level, and poor

human resource management. Though perhaps more damaging has been a historical lack of

stewardship and leadership within the health system at a national level (Coovadia et al. 2009).


Though South Africa is considered a high-‐middle income country, its health outcomes are worse than

many low-‐income countries. Currently South Africa faces a quadruple epidemic, which includes

communicable disease (such as HIV and TB), injury and death due to violence, diseases of poverty (such

as poor maternal and child mortality and morbidity), and rising non-‐communicable chronic diseases

related to diet and lifestyle. South Africa is home to the largest number of HIV infected individuals in

the world, with an estimated 6.1 million infected. Additionally, over 60% of TB patients are found to be

co-‐infected with HIV (UNAIDS 2012). The need for uninterrupted supplies of essential medicines,

particularly for South Africa’s growing burden of chronic communicable and non-‐communicable disease,

is evident.

Rationale South Africa’s overburdened and under-‐resourced public healthcare system regularly struggles to meet

the demands of the public. In addition, poor pharmaceutical logistics and supply chain management

impedes the ability of patients to adhere to treatment regimes, and when combined with poverty, often

deters highly vulnerable households from engaging in health seeking behavior (Goudge et al. 2009).

Regular stock outs of essential medicines at the facility and depot level put patients at risk of developing

poor health outcomes and increase the probability of drug resistance. Moreover, smaller rural clinics

serving traditionally impoverished areas are particularly vulnerable to stock outs because they are

downstream recipients of medicines from larger facilities such as municipal and district hospitals (MSF et

al. 2013). Multiple reviews on access to care in South Africa indicate that poverty, poor healthcare

service delivery, and a lack of clear information from providers disempower patients. In order to

improve the disease burden in South Africa these reviews indicate that novel and innovative approaches

to improve health services are needed (Goudge et al. 2009, Coovadia et al. 2009, Mayosi et al. 2009,

Schneider et al. 2006).

Mobile health technology (mHealth) is a growing field. Innovative uses of technology have improved

information flow, allowed for timely and accurate methods of data collection, and have connected

consumers with providers. Recent pilot programs have looked at how mobile technology can increase

access to medicines by improving accountability within the supply chain of pharmaceuticals (Barrington

et al. 2010). Given that there are 29 million mobile phone users in South Africa, a noted increase from

17% to 76% amongst adults in the past decade, it would be advantageous to explore the ways in which


mHealth can both empower patients and improve access to medicines in low resource settings in South

Africa (KMPG South Africa 2013).

Competencies The competencies to be developed by this analysis into essential medicines access in South Africa are as

follows:

Program Design and Implementation competencies:

• Identify program/project goals, objectives, strategies, activities and resource requirements for interventions that target key global health problems.

• Develop management systems for interventions that address priority global health problems. • Identify information requirements for design, implementation, and evaluation of global health

programs. • Apply design and implementation principals and approaches to a specific program area within

global health.

Topic-‐specific competencies:

• Develop an understanding of the supply chain management system for essential medicines on the national, provincial, and district level in South Africa.

• Conduct a landscape analysis of the current health issues in South Africa as they relate to essential medicines access.

• Review the existing systemic and social challenges to essential medicine access. • Research and compile best practices regarding the use of mobile technology in low-‐resource

setting to improve health outcomes and access to essential medicines.

Methodology Literature in this analysis was located utilizing the databases PubMed and Google Scholar. Peer

reviewed journal articles were limited to the past decade (2004 to 2014), with some exceptions such as

those related to policies implemented prior to 2004. Database searches included the following terms

and phrases:

• South African drug policy • Pharmaceutical supply chain management in South Africa • Access to essential medicines in South Africa • Access to health care in South Africa • Medication stock outs in South Africa


• Mobile technology and medicines access • Mobile health in South Africa • Monitoring distribution of essential medicines • Health impacts of medication stock outs in South Africa

Publications regarding essential medicines and pharmaceutical supply chain systems from multilateral

institutions such as the World Health Organization (WHO) and international agencies were also

considered in this analysis. In addition, applicable policy briefs, news stories, information regarding

mobile health technology programs, and government documents were accessed via the online websites

of the South African National Department of Health (NDoH), associated press, private technology

enterprises, and advocacy organizations.

Results and Discussion Findings from a review of literature related to access to medicines and care, pharmaceutical supply

chain systems, and the role of mobile health technology indicate that little comprehensive research has

been conducted in South Africa on these topics and the relationships between them. Furthermore, few

peer-‐reviewed studies have explored the impact of healthcare access barriers and essential medicine

shortages in South Africa on treatment adherence or overall health outcomes. Topics that repeatedly

appeared in literature searches regarding access to care in the context of South Africa included human

resource challenges and the role of leadership and stewardship in health systems strengthening.

Table 1: Literature sources by topic

Document Year Location Source Type

Access to Care

Access to Medicines

Pharmaceutical Supply Chain

Mobile Health

Technology

Health Outcomes

Aronovich & Kinzett 2001 Kenya Report X

Barnighausen et al 2012 N/A

Peer Reviewed Journal

X

Barrington et al 2010 Tanzania


X X X

Demiris et al 2008 USA Peer

Reviewed Journal

X X

Embrey et al 2009 Global Peer

Reviwed Journal

X


Essack et al 2011 South Africa


X

Goudge et al 2009 South Africa


X X

Gray & Suleman 2000 South

Africa Report X

Harris et al. 2011 South Africa


X

Hozerzeil et al. 2013 Global


X

Kaplan 2006 Global Peer

Reviewed Journal

X X

Leon et al. 2012 South Africa


X

Levitt et al 2011 South Africa


X X

MSF et al 2013 South Africa Report X X X

MSF et al. 2013 South Africa Report X X

NDoH 2012 South Africa Report X

NDoH 2011 South Africa Report X X

Pharasi & Miot 2013 South

Africa Report X

Schneider et al 2006

Southern Africa Region


X X X

Steyn et al. 2009 South Africa


X X

Access to Medicines and Health Care in South Africa

An initial search for literature related to access to medicines in South Africa yielded few results.

Therefore, studies related to public sector health care access in South Africa have been used as a proxy

for essential medicines access. These works have been combined with reports from advocacy

organizations that address nationwide pharmaceutical stock outs.


Despite the great strides that South Africa has made since its democratic transition from Apartheid in

1994, health outcomes remain unsatisfactory. While the South African constitution assures state

sponsored PHC for all, uneven resource allocation, inadequate infrastructure, and skilled human

resource shortages continue to plague the system. It is recognized that equitable universal health care

must be affordable, available, and acceptable to recipients of services. The public health care system in

South Africa rarely meets these requirements, particularly for chronically ill patients (Harris et al. 2011,

Goudge et al. 2009).

Affordability

Affordability is a key component of accessible health care. While PHC services are offered to the public

at no cost, there are often catastrophic out of pocket expenses that affect the most vulnerable and

impoverished populations in South Africa. Due to an inequitable distribution of infrastructure and

resources many individuals, especially those in rural areas, are unable to access care due to public

transport costs. For individuals in lower wealth quintiles in South Africa, transport costs and distance to

PHC clinics are likely to be higher than those for individuals in the uppermost quintiles -‐ who are

generally closer to secondary and tertiary facilities and are more likely to utilize private modes of

transportation. With high rates of unemployment (currently 24.5% nationally), many households in

rural areas are reliant upon government funded social grants as a sole source of income. When

transport costs are combined with limited availability of services and interrupted drug supplies, these

cost burdens can account for 6% to 60% of household expenditure in any given month depending on the

number of repeated trips to obtain medicines and care. Private healthcare services are also frequently

secondary sources of out of pocket expenses for vulnerable groups that are dissatisfied with publicly

funded PHC. In South Africa private healthcare services function alongside public services, delivering

care to those with private insurance schemes or individuals with the ability to pay. These catastrophic

costs can increase household vulnerabilities and food insecurity for low-‐income families. For individuals

without sufficient financial resources, care is often sought intermittently, despite higher rates of

infectious and non-‐communicable disease (NCD) within these lower wealth quintiles (Harris et al. 2011,

Goudge et al. 2009, MSF et al. 2013).

Availability

Availability of healthcare refers to the quantity of fully functioning public facilities, goods, and services.

In an effort to bolster PHC services, several hundred rural primary clinics were built to improve access

for underserved areas. Unfortunately, these rural clinics are plagued with health system weaknesses


and frequently lack adequate infrastructure and skilled service providers. In South Africa the number of

doctors, pharmacists, and nurses required for the public healthcare system to function outstrip the

number of available professionals. Furthermore many of the national human resource challenges do

not reflect the disparities within South Africa – many of these healthcare professionals work in urban

areas, leave the government system to provide care in the for-‐profit private sector, or choose to practice

outside of the country. Over 85% of the South African population is reliant upon public services, and yet

the private system employs 70% of the doctors in the country. Similarly, only 29% of registered

pharmacists work in the public sector. National public sector vacancy rates for doctors and nurses are

currently 56% and 46% respectively, and there are roughly 8 pharmacists providing services per 100,000

people (George et al. 2009, FIP 2012, Gray & Suleman 2000, Schneider et al. 2006).

Few studies have explored healthcare service availability from a beneficiary perspective, of those that

have, drug stock outs were frequently noted as deterrents to care (Schnieder et al. 2006, Goudge et al.

2009, MSF et al. 2013). Two of the national core standards for pharmaceutical services at health

facilities in South Africa ensure that, “medicines and medical supplies are in stock and their delivery is

reliable, and that stock levels and storage are managed appropriately” (NDoH 2011). In surveys

performed by patient advocacy organizations, it was found that 21% of facilities nationwide had

experienced shortages or stock outs of HIV and TB medication, with some rural provinces reporting

stock out rates of over 50%. Vaccine availability was surveyed as a proxy for other essential medicines.

Nationally, 14.7% of facilities had experienced shortages and stock outs of vaccines. Again, rural

provinces experienced higher vaccine stock out rates at over 30% (MSF et al. 2013). Similarly, in a 2011

baseline audit of national health care facilities 77% of clinics, 70% of community health centers, and 98%

of hospitals did not have EDL tracer medications available in the pharmacy or medication storage room

(HST et al. 2012). Patients utilizing the public PHC system report that they are frequently sent home

from health facilities without medication or told to return at a later date. Some patients who are reliant

on lifesaving medications resort to paying out of pocket for essential medicines at private pharmacies.

For chronic patients living in poverty, availability is directly related to affordability, as out of pocket

expenses for repeated attempts to obtain medication can be devastating for the entire household.

Furthermore, a lack of medication and supplies is demoralizing for health workers who are unable to

provide necessary services. Stock outs cause relationships between patients and providers to become

strained, particularly because patients consider access to medication as an indicator of the overall state

of the public health system (Steyn et al. 2009, Goudge et al. 2009, Levitt et al. 2011, MSF et al. 2013).


Acceptability

Studies indicate that anticipated disrespect and ineffective care from providers counteracts health-‐

seeking behavior amongst patients accessing public services in South Africa. Long wait times, unsanitary

facilities, and a lack of privacy and confidentiality were also reported amongst patients expressing

dissatisfaction with public health services. Productive patient-‐provider relations are lacking in South

Africa largely due to overburdened health care professionals resulting from human resource constraints.

However, it should be noted that differences between sociocultural norms amongst providers and

patients also have a large role to play in the acceptability of services and the belief in the efficacy of

treatment regimes amongst patients. A lack of communication and understanding can also negatively

shape the patient-‐provider interaction. Without clear information patients feel that they are unable to

advocate for themselves and often feel disempowered. Such feelings, when combined with medicine

and supply shortages can potentially ruin the trust and relationship between provider and patients

(Schneider et al. 2006, Goudge et al. 2009, Harris et al. 2011, MSF et al. 2013).

Pharmaceutical Supply Chain Management in South Africa

The public sector drug regulatory system in South Africa is founded upon the National Drug Policy of

1996 (NDP). The NDP outlines objectives to improve the availability and accessibility of essential

medicines, quality assurance measures, and rational use of medicines. Initially, the primary goals of the

NDP were to establish an Essential Drugs Programme (EDP) and to develop an Essential Drugs List (EDL)

and Standard Treatment Guidelines (STGs). Compiled and reviewed regularly by experts on the EDL

committee, these documents serve as the foundation of essential medicines access at primary care and

hospital level facilities.

The process of procurement and distribution of medicines begins at the hospital level, where the

Pharmacy and Therapeutics Committee (PTC) at each hospital submits orders and expected drug needs

to the NDoH. Hospital demands form the basis of the medicine quantities requested in the tender

process. The NDoH then manages a competitive tender process with pharmaceutical suppliers. Once

tenders are awarded, suppliers distribute medicines to each of the nine provincial government

warehouse depots. The various provincial DoH offices manage tenders with private logistics companies

to run the pharmaceutical depots. In most provinces, medicines will also be distributed to smaller

district-‐level depots and hospitals, from which small rural PHC clinics will then request stock. These


steps can be visualized within the pharmaceutical management framework proposed by Management

Sciences for Health (MSH) (Figure 1) (Essack et al. 2011).

Figure 1: Pharmaceutical Management Framework (Source: MSH)

Various problems at every level of the supply chain compound medicine access issues for patients at the

rural PHC level. While selection is based on the South African EDL and STGs, government tenders are

often issued for several hundred other medicines that are not associated with the EDL (Gray & Suleman

2000). It is not clear whether this inefficiency is due to oversight or a need to evaluate the tender

process. In a review of tenders for antibiotics from 2007 to 2011 it was discovered that hospital PTC

requests for antibiotics have seen little change, despite expected increases (Essack et al. 2011).

Recently, there have been instances in which pharmaceutical suppliers have been unable to deliver on

tenders that have been offered to them. In early 2013, several thousand clinics reported shortages of

the newly introduced fixed dose combination (FDC) ARVs because the sole supplier could not produce

enough of the FDC pills according to the scheduled contract. In 2012, the Limpopo provincial

pharmaceutical depot was placed under administration and the private logistics company contract was

cancelled when it was discovered that millions of Rand in expired medication were destroyed because

they were not distributed to facilities. Also in 2012, staff at a district pharmaceutical depot in the

Eastern Cape staged a month long strike followed by DoH suspensions for 75% of the staff. A mere 10

working staff members remained to provide services to 300 medical facilities that provide ARVs to over

100,000 patients. Three months following the strike over 53% of facilities served by the depot reported

experiencing TB and ARV stock outs (MSF et al. 2013). At the distribution level, communication issues

between the provincial and district depots and facilities have resulted in drugs not ordered on time or

not ordered at all. These delays are particularly difficult for remote PHC facilities, where supply


deliveries occur on a monthly basis. Despite the use of human resources task shifting and sharing in the

public healthcare sector, these stock issues are made more difficult by a lack of skilled health

professionals such as pharmacists.

It is clear that national and provincial pharmaceutical supply chain management is fragmented. There

are no clear, cohesive, or systematic national standards or procedures for stock monitoring and

reporting. Many medicine shortages and stock-‐outs are underreported, which only exacerbates access

issues, puts patients at risk for poor health outcomes, and inadvertently leads to increased drug

resistance and communicable infections.

Mobile Technologies and Health

Globally, pervasive interest in information and communications technologies (ICT) in health and

development has grown considerably. Enthusiasm for mHealth is based upon the ability to rapidly

collect, store, and collate information in a short amount of time from remote locations. The widespread

use of basic mobile phones, and the limited level of skill or literacy required to use them, suggest that

they are convenient mediums for data collection or limited information transfer amongst diverse

populations in low resource settings (Kaplan 2006, Leon et al. 2012). Furthermore, the role of mHealth

as a means to engender a transition from the role of patients as passive recipients of health care

services to active participants suggests an opportunity for empowerment (Demiris et al. 2008).

Despite broad based policy and debate regarding ICT for health and development, many innovative uses

of mHealth have been confined to small pilot programs and studies conducted within the non-‐profit

sector. Due to the small scale of these studies and their diverse approaches to the use of mHealth, it is

difficult to generalize about the efficacy, value, and impact of scaled mHealth. With the exception of

small mHealth treatment adherence programs for HIV and TB, there is scant literature on the use of

mHealth to improve health outcomes for chronic communicable and non-‐communicable diseases in low

and middle-‐income countries (LMIC). Notwithstanding the success of several pilot projects, few studies

have researched the use of mobile technology to improve pharmaceutical stock levels on a large scale.

While there are small advocacy projects run by local and international civil society organizations that

encourage patient reporting of stock outs, there are no systems of accountability that allow for

bidirectional communication between patients and providers to manage pharmaceutical stock (Kaplan

2006, Barringson et al. 2010, Leon et al. 2012).


There is great potential for the implementation of mHealth technology in South Africa for the following

reasons: (1) At 76% saturation, mobile phone use in South Africa is prevalent in both rural and urban

settings. (2) In comparison to other LMICs, the ICT industry is relatively well developed and there are

diverse mobile network providers. (3) Lastly, there is an enabling policy environment for implementing

mHealth (Leon et al. 2012). In 2012 the National Department of Health released the eHealth Strategy

for South Africa. This document provides a review of policies and a strategic approach for the use of

electronic health informatics in South Africa’s public healthcare system. Within this report, a situational

analysis of South Africa’s capacity for eHealth is provided. The report also defines the ways in which

eHealth interventions can contribute to the strategic objectives of the NDoH. Suggested interventions

include a drug supply and logistics support system, an electronic medical records (EMR) and pharmacy

system interface, an SMS patient reminder system for appointments and medicines, and a

communication mechanism for community health workers (CHWs).

In a review of mHealth in South Africa, Leon et al. is critical of inherent health system challenges that

create barriers to successful implementation of mHealth interventions. These challenges include the

need for leadership and stewardship, the current culture of healthcare service delivery, requisite

systems of sustainable funding, and the ability to integrate mHealth interventions with existing health

information systems (HIS) (Figure 2).

Figure 2: Health systems framework for making decisions about mHealth (Source: Leon et al.)


In the context of mHealth for community-‐based health services, Leon et al. has the following points to

make about each health system dimension:

• Stewardship – The majority of mHealth interventions conducted in South Africa have been

initiated by non-‐governmental organizations (NGOs). Accordingly, they were conducted on a

small scale and did not involve the larger public health system, nor did they require policy

support from the government. Although the NDoH has released an eHealth strategy, there

remains a lack of high-‐level political and financial support from the government for

implementation of mHealth. Stewardship also requires a commitment to establishing public-‐

private partnerships, securing funding, and the identification of best practices for mHealth

interventions.

• Organizational – Although the goal of mHealth is to improve the efficiency of health systems,

the introduction of mHealth interventions present new management challenges. Poor health

outcomes in South Africa are largely attributed to organizational weaknesses, such as a lack of

management and accountability resulting in inadequate service delivery. Furthermore,

healthcare professionals at the district and provincial levels have demonstrated difficulties

utilizing existing health information for management (HIM).

• Technological – Implementing new large-‐scale mHealth programs require user-‐friendly

platforms for diverse stakeholder populations. Stakeholders at all levels must also believe in the

usefulness of the technology and the data it produces. It is important that a new intervention

have the ability to seamlessly integrate into existing HIS. This is a difficult obstacle to overcome

in South Africa, where patient management systems are different for each provincial DoH

(Figure 3).

Figure 3: Patient Management Systems by Province (Source: NDoH)


• Financial – As noted previously, most mHealth interventions in South Africa have been small-‐

scale pilot projects initiated by NGOs with independent funders. Establishing long-‐term funding

for large scale mHealth will be problematic in a system that already exhibits inadequate

stewardship.

Pharmaceutical Supply Chain Management mHealth Innovations in Sub Saharan Africa

SMS for Life

‘SMS for Life’ is a pilot study that was conducted in Tanzania for 21 weeks in 2009 and 2010. The

mHealth intervention focused on improving stock of anti-‐malarial medication at the health facility level

utilizing SMS messages and electronic mapping. Stock counts were conducted at each facility on a

weekly basis and then reported via SMS messages. District management teams were able to view stock

levels through a web-‐based reporting tool that assimilated data from SMS messages at each facility

(Figure 4).

Figure 4: Schematic of SMS system in 'SMS for Life' pilot (Source: Barrington et al.)

Weekly stock visibility allowed district medical officers to redistribute anti-‐malarial medications between

facilities, thereby reducing the risk of stock outs. The ‘SMS for Life’ pilot involved 129 health facilities in

three districts. At the beginning of the program 78% of facilities experienced stock outs of one or more

anti-‐malarial medication, and at the end of week 21 only 26% of facilities reported stock outs. Stock

reporting via SMS remained high at over 93% for the duration of the pilot, though this was likely due to


mobile credit incentives. ‘SMS for Life’ was a public-‐private partnership between the Ministry of Health

and Social Welfare’s National Malaria Control Programme, the Roll Back Malaria Partnership, Novartis

Pharma AG, Vodafone, and IBM. Barrington et al. credit government commitment, adequate mobile

telephone coverage, the use of personal phones, airtime credit incentives, effective training sessions,

and adequate health facility storerooms as project implementation success factors (2010). The ‘SMS for

Life’ model has expanded to include other medicines and is currently being piloted in other SSA

countries.

KEMSA

In 2001 the Kenyan government decided to create a parastatal agency to procure, store, manage, and

distribute medical supplies to public health facilities using private sector logistics and management

techniques (Aronovich & Kinzett 2001). This agency is known as the Kenyan Medical Supplies Agency

(KEMSA), and in 2013 it became a state corporation under the KEMSA Act of 2013. A decentralization of

health services funding and operations to the county level was one of the rationalizations in establishing

KEMSA. Under the new system KEMSA is responsible for procuring supplies with its own funds, ordering

from KEMSA is then completed by counties according to their needs. County governments pay KEMSA

for the supplies and are accountable for the cost of distribution. KEMSA replenishes stock through

profits from sales to counties. KEMSA start up costs were sponsored by the World Bank’s Health Sector

Support Project. Also in 2013, KEMSA announced the launch of KEMSA E-‐Mobile, a partnership between

the Center for Disease Control Foundation, mHealth Kenya, Safaricom, Fintech, Dazzle, and SafeMark.

KEMSA E-‐Mobile is a series of applications and platforms that allow public health facilities and Kenyan

Citizens to interact with KEMSA’s logistic management information system. At the health facility level,

consumption can be reported and supplies can be ordered via mobile phone, this facility level

information is then made available to county health management teams. For Kenyan Citizens, KEMSA’s

E-‐Mobile program provides a level of transparency and integrity, allowing them to anonymously report

suspicious or inappropriate supply issues at health facilities and to inquire about drug availability at their

closest facility via mobile phone. A comprehensive review of KEMSA’s E-‐Mobile initiative has not been

released due to the recent introduction of the program.

iDART by Cell Life

Intelligent dispensing for antiretroviral treatment (iDART) is a software program developed by Cell Life in

collaboration with the Desmond Tutu HIV Foundation, Cape Peninsula University of Technology, and the

University of Cape Town to improve the dispensing of ARVs and treatment adherence within the public


health care sector in South Africa. The system is intended to allow pharmacists to readily and accurately

dispense ARVs, manage EDL stock levels, and generate reports for a growing number of HIV patients.

iDART requires either direct dispensing of ARVs or pre-‐packaged remote dispensing with unique

barcodes that, when scanned, collect patient information. The iDART system is compatible with DoH

monitoring and evaluation mechanisms, thereby allowing for improved reporting for the government

and international donors. In 2010 the Canadian International Development Agency, in collaboration

with Maternal Adolescent and Child Health (MatCH) at the University of the Witwatersrand, designed a

randomized controlled trial to evaluate the introduction of an SMS component to iDART to reduce

treatment interruption and increase adherence amongst new ART patients. Four sites were chosen for

the RCT, which was completed in late 2013. To date results of this study have not been published.

Limitations This analysis was limited by relatively scant literature on the role of mHealth to improve supply chain

management of essential medicines in low resource settings. Furthermore, the existing literature

generally features small scale mHealth interventions initiated by NGOs with fixed funding and project

time scales. There were difficulties finding comprehensive information on the process of

pharmaceutical supply chain management in South Africa because national LIMS are fragmented by the

decentralization of public healthcare services to the provincial level and the privatization of

pharmaceutical distribution. Lastly, very few studies have investigated patient perspectives on access to

medicines and healthcare in South Africa, or the potential to integrate bi-‐directional mHealth

communication systems with patients to improve supply chain management and access.

Conclusions and Recommendations Despite spending more money on healthcare than other LMICs, South Africa has unacceptably poor

health outcomes. Additionally, South Africa is also home to the largest populations of individuals

affected by HIV and TB -‐ considerable constituents of the quadruple disease burden, of which the other

three are NCD, poor maternal and child health, and violence. Human, financial, and physical resources

remain inequitably distributed within the South African health system in spite of the gains that have

been made in the public healthcare sector following democratic transition in 1994. Rural and

impoverished populations within South Africa consequently bear the brunt of these inequities.


With over 2.1 million individuals initiating treatment, South Africa operates the largest ARV program in

the world. However, tracking treatment compliance and loss to follow up remains an obstacle. South

Africa is also the epitome of a country in transition and chronic NCD is on the rise. The disease burden

in South Africa necessitates a regular and reliable supply of essential drugs for chronic illnesses.

Impoverished patients are constrained to utilizing PHC clinics with few resources. In reviews of the

South African PHC system patients report poor service delivery and regular shortages of medications.

Patients are often told to return to facilities at a later date to collect out of stock medications. Patients

within the public healthcare sector generally choose facilities based on distance in order to reduce the

economic impact of transport costs, however, repeated attempts to obtain medication can result in

catastrophic costs for the entire household. Inadequate access to medicines may lead to treatment non

adherence, potential development of resistant strains of TB, HIV reinfection, and poor health outcomes

overall – though there are no known studies to confirm this relationship. The economic impact of these

consequences are also unknown.

Pharmaceutical supply chain management within South Africa is controlled at the provincial level, with

NDoH heading the tender process for obtaining supplies and medicines. The quasi-‐provincial

implementation of drug delivery and public health services creates a difficult environment with which to

streamline HIM and data collection for improved decision-‐making. Multiple advocacy organizations

have documented essential drug stock outs resulting from the inefficiencies of supply chain

management in the public sector.

MHealth has the potential to empower South African patients by connecting them with necessary

information, such as facility-‐based drug availability. Additionally, bidirectional communication

transforms the traditional patient role from passive recipient to active participant in the health care

system. Initiating large-‐scale participatory mHealth in South Africa to improve the pharmaceutical

supply chain will require leadership and stewardship at all levels. Previous mHealth pilot projects have

demonstrated the importance of public-‐private partnerships. A scaled mHealth innovation will require

sustainable funding, the identification of stakeholders, and the involvement of multilateral agencies,

civil society organizations, academia, the private ICT industry, and the South African government. It

would be advantageous for the South African Government to build on the successes of existing

pharmaceutical supply chain management mHealth programs in SSA.


Widespread mobile phone use, an advanced ICT network, and an enabling policy environment suggest

that the potential to implement mHealth in South Africa to improve supply chain management is great.

However, it should be noted that introducing mHealth will likely create additional management

responsibilities. In South Africa there are skilled human resource shortages in the healthcare sector and

an unfavorable culture of service delivery. Until such resource constraints can be ameliorated, it is

unlikely that introducing innovative approaches will produce beneficial results.


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Edmondo Aimee PHA Final Spring 2014

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