Sustaining SIAPS’ impact: What’s next for pharmaceutical systems strengthening?

By Francis Aboagye-Nyame, SIAPS program director

Greatjoy Mazibuko was a pharmacist at the Oshakati Intermediate Hospital in Namibia working with ART patients. Every day, he rose at dawn, not knowing how many patients he would have that day. He often worked for 12 hours or more; patients were kept waiting for hours, perhaps having traveled for hours, not knowing when they would be seen or if they could get the medicines—including life-saving ARVs—they needed, as the health facility had frequent stock-outs.

The SIAPS Program began working with the Ministry of Health and Social Services in Namibia in 2011. Among other activities, the program helped enhance and customize the Electronic Dispensing Tool (EDT) for use at all ART sites in Namibia.  The EDT helps manage ART patient, medicine, and regimen registration. EDT also managed baseline and outcomes for CD4 counts, viral loads, adherence and logistics data and helped pharmacists manage medicine stock.

That’s not all the program did in the country. A facility electronic stock card simplified stock inventory tasks, allowing pharmacy staff to spend more time caring for patients. EDT supported the introduction of short message service prescription pick-up reminders at 10 ART sites to enhance patient adherence to treatment. The SIAPS program also supported pharmaceutical management training for more pharmacists, including helping in the development of new national pharmacy school curricula. It helped develop a guide for AMR advocacy and containment interventions and supported reporting on adverse drug reactions. SIAPS also supported the streamlining of operations at the Namibia Medicines Regulatory Council to get quality-assured medicines to market faster and established and supported review of the Namibia national medicines policy.

Pharmacists like Greatjoy can now plan how many patients to see each day. They can prepack and double-check medicines, dispense and track medicines more quickly and accurately, and close their windows at a reasonable hour. They have time to counsel patients on how to take their medicines and the knowledge of what to do if there are adverse reactions. Data on ARV dispensing and ART patients, thanks to the EDT, automatically goes to a national database to help inform procurement and maintain stock levels, so there’s no need for manual input. A dashboard shows pharmaceutical and ART data for users in more than 50 facilities countrywide.

This one story is a microcosm of SIAPS’ impact in making sure people have timely access to safe, affordable medicines and to well-trained pharmacists who can provide quality services to improve their health. Funded by USAID, the program worked in 46 countries to comprehensively strengthen pharmaceutical systems by addressing five interrelated functions, with a focus on medical products—governance, human resources, information, financing, and service delivery. (For more information, please see the SIAPS final report.) A few highlights:

Policies, laws, and governance To make sure that medicines are safe, countries need to have supportive legislation in place and must be able to enforce it. With SIAPS’ help, a number of countries developed or revised their national medicines policies and developed dozens of laws or regulations. Eleven countries improved product registration to help move quality medicines to market faster.

Human resources Delivering the right medicines and making sure they’re used appropriately requires skilled health care workers, managers, and leaders that have up-to-date knowledge and skills. SIAPS built institutional capacity, helping pharmaceutical leadership in many countries develop terms of reference and organograms. The program also supported training of tens of thousands of people at all levels in pharmaceutical management.

Information for decision-making More than 150 countries use the 7 electronic Pharmaceutical Management Information Systems SIAPS developed and enhanced to help them make more evidenced based, accurate and timely decisions for patient care and pharmaceutical management. Data-based decision making is critical to supporting countries’ disease-specific programs, such as TB, malaria, HIV, and RMNCH and their essential medicines programs.

Financing Medicines contribute significantly to the overall cost of health service delivery and account for a sizeable proportion of out-of-pocket payments, which can lead to crippling expenses for individuals and remains a major obstacle in achieving good health outcomes and reaching universal health care goals. Efficient pharmaceutical management is key to cost containment (see our report on this topic), as are innovative, country-specific ways to maximize resources. SIAPS helped countries save more than $120 million through revised formularies and improved procurement, quantification, and stock redistribution.

Pharmaceutical products and related services Ensuring that medicines are available, affordable, and safe means both addressing supply barriers and examining the quality of prescribing and adherence to treatment guidelines. SIAPS took a holistic approach to addressing supply chain issues, including capacity building in supply management and standardizing and streamlining logistics systems and processes. The program also implemented pharmacovigilence activities in a dozen nations; created and revitalized more than 500 drugs and therapeutics committees; and helped countries develop national strategies to fight AMR.

Looking forward

 Each level of progress in pharmaceutical systems strengthening (PSS) sets the stage for further advances. Which areas need focused attention going forward?

  • Countries need to consistently measure how well systems strengthening projects work, to set priorities and better guide country and donor investments. Some areas of research are still nascent; for example, how do we define what constitutes a resilient, sustainable system that can withstand shocks and challenges? That’s a need that came to light after SIAPS helped a number of countries recover after the Ebola outbreak, and which is critical as we all work to avoid future pandemics. To that end, SIAPS and its partners have proposed a definition of pharmaceutical systems and pharmaceutical systems strengthening and have developed a new framework, PSS Insight, for countries to measure progress. We need to know which activities contribute to a more resilient, responsive pharmaceutical system in the long run, versus improvements in specific functions that may not ultimately increase access to and appropriate use of medicines over the long term.
  • If supportive policies are not in place, we cannot move forward with system strengthening interventions. Strategies that strengthen the capacity of institutions or organizations to implement policy and enforce regulations are critical to improving the efficiency and effectiveness of the pharmaceutical system and will aid in reducing the overall cost of health service delivery.
  • We also need to continue to build human resource capacity, training more pharmacists and health workers and implementing reasonable task shifting strategies to address issues of supply and service delivery.
  • We need to build a body of peer-reviewed literature. There’s an increasing amount of writing on health systems strengthening, but much less so specifically on the critical component of pharmaceutical systems strengthening.
  • A systems approach needs to build on existing structures, including the private sector. The global development field can and should develop innovative public−private partnerships toward shared goals.
  • We are in the information age, and we need to know how to use it. This means working with countries to institutionalize information management at all levels of the health care system and help them better use existing data for decision making. Data gleaned in new ways, such as via smart phones and Twitter, SMS, WhatsApp, etc can be usefully integrated into traditional data sets, too.
  • There are a number of areas that need more attention in PSS going forward, including innovation; researchers and developers need capacity building along with other health sector workers. Trade issues are important, too, as they influence how pharmaceuticals enter the system and how they are traded.
  • As global support grows for financial protection programs and the commitment to achieving the UN Sustainable Development Goals (SDGs), we need to keep reminding leaders of the critical role medicines play in quality health-service provision.
  • The current funding environment tends to be siloed into health areas, with governments implementing activities accordingly. Yet effective pharmaceutical management is critical to success in all health system activities, and PSS lays the foundation for sustained, progressive improvements. We must therefore continue to advocate for funding dedicated specifically to PSS work.

SIAPS is a model of how strengthening the foundational components of pharmaceutical systems can contribute to their effectiveness and resilience. We need to continue pushing for progress to ensure that everyone—despite their circumstances—gets the medicines and care they need to make and keep them healthy.

Click here to read the SIAPS final report.