Last post I talked about the technical exchange meeting we held in October in order to identify the challenges in the medicines supply chain and brainstorm on potential solutions.
I recently found a report written in 2008 (USAID/Haiti Maternal and Child Health Portfolio Review and Assessment) with a section on the health sector logistics in Haiti. I was a little stunned to read a description that is quite similar to what was discussed at the technical exchange meeting, as well as what I have observed through my meetings with NGOs and other parties. This means that two years later, there hasn’t been much improvement. Maybe this shouldn’t have been very surprising, but it is quite troubling.
Here is most of the section. The whole thing is interesting, but since it’s already quite long I cut out parts which I thought were not necessary for a general understanding of the situation.
HEALTH SECTOR LOGISTICS MANAGEMENT SYSTEM
The health sector logistics management situation has been anarchic for many years. The national system is woefully inefficient and ineffective.
Although PROMESS is referred to as the central procurement agency of the MSPP [Ministry of Public Health and population], it remains a PAHO/WHO project to this day. Designed during a crisis [during the embargo period in 1992] to procure, store, and distribute essential drugs, once the embargo was lifted the MSPP and donors continued to view PROMESS as the central agency in Haiti‘s drugs logistics system, without seriously reassessing its status as a WHO project or determining if the hastily established agency responded appropriately to the country‘s needs and constraints. The 17 departmental drug depots (Centres Départementaux d‘Approvisionnement en Intrants, or CDAI) still have no legal status, and it is unclear who is responsible for their maintenance and upkeep (MSPP central? MSPP regional? WHO?). As a result, most of the CDAIs have not been maintained and are in poor condition, albeit a few of them have benefitted from donor renovations.
Moreover, there is a lack of communication at all levels of the logistics system (between central level MSPP and the departments, between and within departments; between MSPP central departments and PROMESS). There are frequent stock-outs, untrained and demotivated staff, unclear procedures, poor forecasting, weak supervision and management, deficient technical capacity, and no active distribution of drugs and supplies. While there is general agreement that the logistics system is within the MSPP‘s mandate, the MSPP lacks the financial, material, and human resources to manage and maintain the system. The DPM/MT (Direction de la Pharmacie du Médicament et de la Médicine Traditionnelle) is the MSPP regulatory body. Moreover, there are several MSPP technical offices that play a role in the system, even if it is not entirely clear what those roles are. There seems to be little or no coordination of activities, no oversight, and no accountability.
The chronic stock-outs of basic drugs and supplies at health facilities have led to the creation of parallel procurement and distribution systems by international organizations (USAID, the Global Fund to fight AIDS, Tuberculosis and Malaria, World Vision, Médecins Sans Frontières, and others) and private clinics and hospitals. It is reported that even some public-sector facilities have set up their own drug procurement systems. The MSPP feels that these parties have usurped its role as manager of the sector’s logistics system, while the parties justify their unilateral action (parallel systems) by asserting that the MSPP does not have the capacity to set up and run a viable system. Both sides have legitimate grievances, but to continute the finger pointing is counterproductive. The challenge is to design a system that is cost-efficient and operationally effective in meeting the different needs of health care facilities nationwide. The only good thing about the current dysfunctional situation is that it provides an opportunity to start anew. Once the vision of a new system is clear and agreed upon by all parties, the next challenge is to elaborate a coherent plan and define steps to be taken to set up and launch the system. To be successful, the plan requires widespread support and participation by all concerned parties.
In May of this year , the MSPP issued a ―Plan to Strengthen the National Essential Drugs and Supplies System in a document entitled Projet de Création du Réseau National de Distribution des Intrants. … [work on this project, now referred to as Système National Logistique des Intrants, is ongoing – 3 main scenarios for a national medicines logistics system have been outlined – however since this involves political endorsement, it is highly unlikely that any decisions will be taken before the new government is in place, which means also not counting on real implementation very soon]
The private for-profit pharmaceutical … sector prefers to import products that enable the largest profit to the detriment of basic essential drugs. From all accounts, the private sector is not able to satisfy the demand for medicines and its distribution systems are also unorganized. People come to Port-au-Prince to stock up on medicines, going from agency to agency trying to negotiate the best deals. Even the private sector has stock-outs from time to time. … Suffice it to say that the needs of the Haitian population are not being met satisfactorily by either the public or private sector.
Some things have changed, and I don’t know how accurate every detail of the report is, but the general picture is remains quite faithful to the current reality. The part in bold makes me think about Michael Keizer’s post about whether or not to set up a parallel supply system (and the issue comes back below). I also think the part about moving beyond grievances – even if they are legitimate – toward constructive solutions (or at least improvements) is important if something is going to change before another two years pass by. In terms of structural improvement on the whole supply framework, much can come out of the new national logistics system if it is well designed and well implemented – I don’t know enough about the options it currently outlines to pronounce myself on this, but what we do see is that the first plan was already drawn two and a half years ago…
What is IDA’s role in this story? We are not governmental policy-makers or demanding donors. We are a supplier of medicines and medical equipments, specialising in wholesale, procurement services, tenders, and anti-retrovirals. This means we can definitely share our technical experience in terms of logistics, supply chain management, quality assurance, etc. But we are not the ones to design and implement a national medicines logistics system.
Essentially, that is why I am here: to find out how we can further contribute to our mission in Haiti, i.e. improving access to medicines, through our role as a supplier. This implies two questions. First, is there an actual need to improve the medicines supply chain? The above passage is a good summary to conclude that yes, there is a clear need, as “the needs of the Haitian population are not being met satisfactorily” by the current systems in place. In my opinion this has also been confirmed in pretty much all of my meetings so far, as well as at the technical exchange meeting.
The second question is whether IDA can actually be a contributor to respond to that need: maybe there is a need, but we are not the right party to respond to it. That conclusion would be a little disappointing for IDA, but it would be fair enough. So far however, my conclusion is that there is definitely a role for IDA, even within the ‘constraints’ of our role as a supplier.
Basically, we can do either one or both of two things: a) be a catalyst and contributor in the structural improvement of the ‘national’ supply chain, b) improve our service as an ‘alternative’ supply chain. So after having answered these two questions, one of my main activities is to (try to) map out these options in a concrete manner – both include several sub-options, so I’m looking at what the needs are, and the services that we can offer to respond to this need (evenutally in partnership with others), what the different options would require from IDA in terms of people, organisation, and investment, and of course what effects they are most likely to have.
One of the challenges of the assignment is when ‘concrete’ means being able to put numbers on, for example, what the actual needs are – with such a fragmented group of NGOs and public institutions, it’s hard to get an overview. Similarly, in this context it’s hard to know in advance what the effects of a project would be. But well, that’s the whole point: I’m trying to gather as much relevant information as possible to enable us to judge the best course for now.
The backdrop to this interesting assignment is a worrying perspective: identifying challenges and opportunities does not actually guarantee change in the future. This report was written two years ago, and I reasonably suspect it was the same four years ago too. So for the years to come, more of the same? I hope not!