Medicine supply in Haiti: more of the same?

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 [2008], 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!

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Technical exchange meeting

The reporting is a bit late since this happened in October, but anyway: what kept me (very) busy the first half of October was the organisation of a ‘technical exchange meeting’. On October 19th, around 50 people from 30 different organisations came together for a day to discuss the medicines supply chain in Haiti. IDA’s Managing Director, visiting from the Netherlands, led the discussions. Keep reading for anecdotes, or see the brief news item on the IDA website.

The organisation of the day took a lot of emails, phone calls, and visits – I was, uhm, let’s say complimented, by the Chief of Staff of the Ministry of Health on my ‘persistence’ in trying to reach him and organise an appointment. It is true that this persistence was sometimes a little stalker-like; contact information is in one way very difficult to find in Haiti for someone who doesn’t have an existing network to start with. Emails come back with messages of error, and phone numbers regularly don’t work or change. With NGOs you don’t know if someone is still in their current job or already in another country (especially after the earthquake where there were many short-term jobs). With the government information online might not be updated, and official email addresses sometimes have full mailboxes, so it’s better if you know someone’s personal email. So this all took a fair amount of browsing NGO contacts database, asking around as I got to know people, and yes, asking Google too.

On the other hand, contact information can be very easy to get when you find the right person – in the case of the Chief of Staff, I had found the number of the previous one, called him, and he kindly gave me the phone number of the actual one. Even better, when I called the actual one, he did not pick up a few times – but then he called my unknown number back. That made my day. Still, the job was not done yet, because though we agreed on a meeting day, we did not have a meeting time until a week later. And then on the day of the meeting I remembered – always call again when you are ready to leave. This proved essential, because he had actually forgotten our appointment in the midst of many. Still, in the end, we had a good meeting, he introduced us to the General Director of the Ministry, who also honoured us by opening the Technical Exchange Meeting the next day.

Dr. Thimothé, Directeur Général MSPP, opening the technical exchange meeting

Now, it’s fun to tell this story with the Chief of Staff, since he’s an extremely busy man and the chance of getting in touch with his counterpart in The Netherlands in the same way is quite small, but it basically took similar exercises to invite others to the meeting. There was one hospital I had had no reaction from, so one day I decided to drop by. Incidentally, this was the day where I really learned to always call again while you are ready to leave; I had gone to the car rental agency without calling in advance, so they didn’t have the documents I needed. We agreed I would come back early the next day. This had been agreed, but I thought ‘let’s call while I’m on the way’. Smart, but not smart enough, because after a half hour drive, I learned the documents would only be there an hour and a half later. I could drive back a half hour, but then would have to turn around immediately again as it is an hour’s drive. Or I could wait there with nothing to do for an hour. Well, luckily, I remembered I was close by this hospital, so I thought at least a few minutes would be well spent by paying their pharmacy a visit. This turned out very well, because the hospital had been having electricity issues, and so the pharmacist hadn’t been able to check her email and know about our invitation!

Anecdotes aside, it ‘all turned out well’. We were particularly happy to have not only NGO’s but also public hospitals, other medicine suppliers, freight forwarders, the government, and the WHO/PAHO’s PROMESS project (which acts as central medical store). The medicines supply chain in Haiti is really not the most efficient right now (post coming up on that), and solutions have to come from all sectors involved. After introductions, we first identified the challenges that the participants were facing, and then we brainstormed for solutions.

Technical exchange meeting on the medicine supply chain in Haiti

Of course, that is only a small first step – then comes the actual work of choosing the most adapted solutions and implementing them, which depends on all actors to play their part. So it was nice that things went smoothly, with good representations from the main actors and constructive discussions, a week later it was a bit of an anti-climax: now what?

Well, that’s for the next post!

Meanwhile, a few more photos from the exchange.

Dr. Klopfenstein presenting the PAHO/WHO PROMESS project

Mme. Joseph presenting the DPM/MT

Making posters to identify and categorise challenges

Groups checking out each others' challenges before plenary discussion

Brainstorming on potential solutions

Edwin de Voogd, IDA Managing Director, gets interviewed

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On the walls: part 3

A few more, I took these this week.

Another 'Jezz'

 

Marketing within marketing

 Digicel is one of the two main telecom providers here, and an extreme practitioner of marketing. Basically, it’s everywhere: on the walls, on the radio, as a sponsor of most big events.. What I find funny about this wall-advertisement is the way it features other Digicel advertisements – just like on the wall, there are many Digicel umbrellas, backpacks, t-shirts, etc. I haven’t seen a Digicel bench yet though.

Its competitor Voilà is pretty much the same, though a little less. They are two of the largest companies in Haiti, so the extent of their marketing arm is not surprising.

Phone credit is sold on the street by people wearing a kind of apron that signals them as a Digicel or Voilà vendor, respectively red or green (usually they sell both though). This is such a common, typical sight here that a friend told me she would dress up as ‘a Digicel guy’ next Halloween.

Vote Alix!

This one is not that interesting, but it’s funny to see my name tagged on some walls. When I pointed out the apparent fact that I was taking part in the elections to Bastien, he laughed with me: ‘you have become Haitian!’ ‘I’ve also become a man,’ I replied, as the Alix running for député is a man. Actually, most Haitians assume I am one too when we’ve only communicated by email, it’s a guy’s name here.

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On the walls: part 2

My mom was here last month, and she is in general a better photographer, with a better camera, and less shy about taking pictures than me – so the next few posts will include her photos, as these three below to continue the ‘walls’ series.

Election graffiti and red MTPTC sign

MTPTC is the Ministère des Travaux Publics, Tranports et Communications, which undertook large-scale building damage assessments after the earthquake (with the support of partners). Red = dangerous building, entrance forbidden, to be demolished or requiring major repairs. Yellow = dangerous building, limited entrance, requiring minor to moderate. Green = not damaged or superficial damage, immediate occupation/return is safe. By July 182,850 structures had been assessed, 47% green,  27% yellow, 24% red. I will try to find more updated figures.

The blue graffiti says “change = Baker”, who is #40 on the election list.

Visual marketing

Little shops are in general very visual in their marketing. If you can eat chicken in the restaurant on the street, there will probably be a chicken painted on the front. If the shop sells ‘diverse products in retail and wholesale’, these will be listed on the front, usually in paint too, sometimes in creative fonts (pictures coming soon). So in this case, it’s also clear what Nick’s Exterminating exterminates!

The way products are sold on the street is also very visual, products stacked in high piles so that each is visible, pretty much in a ‘you can’t buy what you can’t see’ fashion (again, pictures coming soon).

Another wall

Less special than the artistic graffitis or entertaining store-fronts, this is a pretty standard wall for these days. Election posters and graffiti. The ‘Studio de Beauté’ sign on the bottom left indicates the building housed a beauty parlour on the ground floor before the earthquake. The state of these buildings is still very, very common.

P.S. – For those interested in health/development/access to medicines/aid logistics, I’ve added a new section with useful resources. Recommendations are welcome. I also updated some practical details about living in Haiti (at the bottom of ‘More on Haiti’) for anyone moving here soon or new in the country.

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On the walls: part 1

There is a lot of life on the walls in Port-au-Prince: (election) graffiti, election posters, graffiti art, the label from the Ministry of Public Works and Construction to say whether the building is safe to live in or not after the earthquake, and many advertisements! Three graffitis for today:

A personified Haiti in the national blue and red; woman and children under rain

A crying man

One of my favourites

P.S. – I have been a little lost in my own thoughts, to explain the recent lack of posts. Also, some photos of walls might be a bit thin for those expecting commentary on what everyone sees on the news. As a quick update:

Hurricane Tomas (5.11.2010) definitely did some damage, destroying (flimsy) homes and causing floods and mudslides, but it was luckily not as bad as feared. Some of the worst affected areas (especially on the coast south of Port-au-Prince) are also some the worst affected areas after the earthquake. Haiti doesn’t get it easy…

For those who want to know how it was like for me: I was simply in my apartment, with a large stock of canned foods and that kind of thing, just in case. The water reservoir on the roof was filled to be sure to have enough water – and so the roof wouldn’t fly off. But it was not very dramatic, a lot of wind and rain pouring for hours. I live in an appartment on the bottom floor, which is partially under the street level, so it’s all quite protected from the wind, it was a lot more dramatic in other places.

Cholera: “Over 12,000 Haitians have so far been hospitalized for cholera, and over 800 people have died from the disease, which is spread by contaminated food and water. Up to 200,000 cases of cholera are expected to be reported over the next 6 to 12 months.” (UN News, 15.11.2010) NGOs and the government are working really hard in their response, both in terms of prevention (a lot of community training, radio announcements, soap distribution, etc.) and treatment (procurement of medicines and supplies, setting up Cholera Treatment Centers, delivering treatment, etc.)

For those wondering about me again: I have been a little involved, liaising partners here in need of medicines and supplies with IDA in Amsterdam, and in touch with the Ministry of Health on how else we can contribute. However, I am by far not as busy as those working for the medical NGOs and local organisations and hospitals of course, who are under a lot of pressure. And I’m healthy, eating clean food, drinking clean water, washing my hands, no worries for my health.

The upcoming elections are regularly causing demonstrations, sometimes not entirely pacific (throwing stones at cars), but it’s hasn’t been very dramatic either. Though today I did hear there had been some shooting in Jérémie (city at the end of the south-west part of Haiti), but couldn’t confirm it yet. The four names I hear most often in terms of favourites are Jude Célestin, Mirlande Manigat, and Jean Henri Céant, and Jacques-Edouard Alexis.

On the other hand, there was violent protest in Cap-Haitien (on the north coast), but this seems more related to the fact that some Haitians have grown suspicious of UN facilities after a rumour began that a peacekeepers’ camp was the source of the original cholera outbreak. Official response is that this is in no way proven and that the source is probably impossible to identify.

I am careful as usual and keep up with some sources to try not to end up somewhere at the wrong time, but I did happen to drive through the beginning of a demonstration once. It was quite calm and we drove through in about a minute. Like I said, I am careful. The days around the election I will stay home.

Soon… more wall photos. I like sharing more of Haiti than its disasters and politics.

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When you don’t know

“…I would like to beg you … to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.”

Letters to a young poet, Rainer Maria Rilke

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Cholera outbreak

For everything that has not improved since the earthquake, one positive thing had so far been no major disease outbreaks. Now:

“Government officials confirmed a cholera outbreak in the Département Artibonite. The Ministry of Health reported the worst-affected areas were Douin, Marchand Dessalines and areas around Saint-Marc, approximately 100 km north of Port-au-Prince. More than 1,500 people are reported to be sick. The diseased suffer from severe diarrhea, which leads to extreme and rapid dehydration, which led to death in at least 141 cases so far. The Artibonite River is likely to be the source for the outbreak, after recent heavy rains spurred its banks to overflow and flooded the area.”

Poor water and sanitation facilities is the best way for cholera to spread quickly, and this is definitely an issue, especially in the IDP camps. The government is preparing an information campaign on prevention. Medical NGOs are getting ready to set up Cholera Treatment Centers as soon as they receive the authorisation.

In the midst of all this activity, I do feel quite powerless. The office in Amsterdam is currently checking our stock on the specific products needed for cholera treatment, and contacting suppliers in case we need more. IDA will of course do its best to provide what is needed quickly, but we can’t do much before actually receiving orders from NGOs or the government.

While I am powerless in the face of pretty much all challenges here, this is in the health sector, so it feels closer.

An American who grew up in Haiti and is currently involved in reconstruction efforts told me that it was important for people/relief workers to stay focused on their specific tasks – not only does it allow them to work better by focusing their energy, but worrying about all the different problems is too heavy. It’s not that you shouldn’t consider what is going on around you and outside your own work, but constantly facing all of the suffering head-on is too much of the opposite. I think that was good advice, and think of it when I feel particularly powerless.

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