A 2009 SPS study[1] determined that the primary cause of inefficiencies and stock-outs was the fragmentation of the supply process into multiple vertical systems organized around disease control programs.
Based on these challenges, the Ministry of Public Health requested technical assistance from USAID[2] to implement the Integrated System for Medicine and Supply Management (Sistema Único de Gestión de Medicamentos e Insumos; SUGEMI).
In 2010, a Ministerial Decree established SUGEMI as the institutional mechanism for organizing the pharmaceutical supply system in public health care facilities.
Project Highlights
Since 2012, USAID funding through SIAPS has enabled the reorganization of the pharmaceutical supply system using a systemic approach across all health system functions that contributed to improved access to medicines.
The following activities and processes contributed to the organization of SUGEMI:
– Eighteen manuals and operating procedures for the implementation of SUGEMI in primary care units[3] and hospitals[4]
– Six operating procedures on transport logistics of biological samples[5]
– Training of 6,000 specialists responsible for implementing the SUGEMI operating procedures
– Estimating and procuring medicines and supplies for HIV, tuberculosis, hospitals, and primary care units
– Certificate courses in pharmaceutical management[6] and rational medicine use launched
– Seven financial gap studies regarding financial resources for the procurement of ARVs and other medicines[7], [8],[9],[10],[11],[12],[13]
– Three studies and proposals for improving warehouse conditions[14]
– An updated Essential Medicines List,[15] the high-cost medicines list,[16] the over-the-counter medicines list, the Primary Care Unit Diagnostic Guide, and the First-Level Care Therapeutic Formulary
– The availability of ARVs increased from 76% (2011) to 96% (2016), while availability of medicines for non-communicable diseases increased from 71% (2011) to 92% (2016). [17]
– Despite a limited increase in the allocated budget for the purchase of medicines since 2011 and no reduction in the price of medicines during this period, the quantities of medicines and medical commodities acquired doubled by 2015. A probable explanation for this finding is SUGEMI’s introduction of a standardized methodology for the estimation of procurement needs (figure 1).
Figure 1. Availability of general-use medicines in first-level health facilities in the Dominican Republic (2011–2015) [Click to enlarge]– Towards the end of 2014, the USAID investment was having a positive financial return: for each dollar that USAID invested, the Dominican government could save or mobilize USD 601.[18]
Therefore, mobilization of national and international resources to improve the infrastructure of regional warehouses and the achievement of significant savings in the purchase of general-use and high-cost medicines resulted in additional resources available for the procurement of medicines.
Figure 2. SIAPS activities in the Dominican Republic [Click to enlarge]
Project Legacy
The transition from a vertical to an integrated supply system produced operational efficiencies in the Dominican Republic. Efficiency at SUGEMI increased the availability of ARVs and essential medicines for first-level use and generated significant savings for the government.
The design and implementation of SUGEMI in the framework of national initiatives (health-sector reform and the decentralization of the state) enabled institutionalization and enhanced sustainability of interventions.[19]
[1] SPS stands for Strengthening Pharmaceutical Systems. The USAID financed MSH’s program on pharmaceutical management that preceded SIAPS.
[2] MSH implemented the SPS Program until 2010 and the SIAPS Program from 2011 to the present.
[3] SUGEMI. Manuales y Procedimientos Operativos para la Gestión del Suministro en Unidades de Atención Primaria. The manuals and operating procedures are available on the electronic page of the Ministry of Health of the Dominican Republic: Directorate of Development and Strengthening/SUGEMI. http://www.sespas.gov.do/documentos-sugemi.
[4] SUGEMI. Manuales y Procedimientos Operativos para la Gestión del Suministro en Centros Especializados de Atención. The manuals and operating procedures are available on the electronic page of the Ministry of Health of the Dominican Republic: Directorate of Development and Strengthening/SUGEMI.
[6] Barillas E, Valdez C, Diaz P, Tapia ME. Combined on- and off-site training contributes to strengthening the unified pharmaceutical system in the Dominican Republic. Journal of Pharmaceutical Policy and Practice 2014;7(Suppl 1):O24. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4304317/.
[7] Strengthening Pharmaceutical Systems. Policy Brief: Programación de la compra de medicamentos e insumos médicos del Ministerio de Salud para el 2012 y sus implicaciones para mejorar el abastecimiento en República Dominicana. Presented to the United States Agency for International Development by the Strengthening Pharmaceutical Systems (SPS) Program. Arlington, VA: Management Sciences for Health; 2012. Available at: http://projects.msh.org/projects/sps/SPS-Documents/upload/dr_policy_brief_improving_supply_aug2011_sp.pdf.
[8] Systems for Improved Access to Pharmaceuticals and Services (SIAPS). Análisis de alternativas para el financiamiento de medicamentos antirretrovirales en República Dominicana, noviembre 2012. Presented to the United States Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health; 2012. Available at: https://siapsprogram.org/wp-content/uploads/2013/01/13-072-Alternativas-para-el-finaciamiento-de-ARV-SP-FINAL.pdf.
[9] Ministry of Public Health of the Dominican Republic, Directorate of Development and Strengthening of the Regional Health Services (Dirección de Desarrollo y Fortalecimiento de los Servicios Regionales de Salud, or DDF/SRS), National Medicine Management Unit (Unidad Nacional de Gestión de Medicamentos, or UNGM). Programación para la compra en el 2014 de medicamentos e insumos médicos en República Dominicana. Santo Domingo, Dominican Republic; April 2013. Available at: https://siapsprogram.org/publication/programacion-para-la-compra-en-el-2014-de-medicamentos-e-insumos-medicos-en-republica-dominicana-2/.
[11] National Medicine and Supply Management Unit, Ministry of Public Health. La programación de la compra de medicamentos e insumos en el Sistema Público de Salud de República Dominicana. Santo Domingo, Dominican Republic; July 2014. Presented to the United States Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health. Available at: http://apps.who.int/medicinedocs/documents/s21651es/s21651es.pdf.
[12] National Medicine and Supply Management Unit, Ministry of Public Health. La programación de la compra de medicamentos e insumos en el sistema público de salud de República Dominicana. Santo Domingo, Dominican Republic, September 2015. Presented to the United States Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health; 2015. Available at: http://apps.who.int/medicinedocs/documents/s22175es/s22175es.pdf.
[13] Valdez C, Barillas E, Castillo M. Historia de éxito: El financiamiento de ARVs en República Dominicana. Presented to the United States Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health; 2015. Available at: https://siapsprogram.org/2015/09/14/el-financiamiento-de-arvs-en-republica-dominicana/.
[16] Narváez E, Valdez C, Barillas E. Revisión de la lista de medicamentos de alto costo del Programa de Enfermedades Protegidas de República Dominicana y programación para la compra en el 2015. Santo Domingo, Dominican Republic, July 2014. Presented to the United States Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health; 2014. Available at: https://siapsprogram.org/publication/high-cost-medicines-dominican-republics-planning-of-purchases-2015/.
“As the SIAPS project comes to a close, I want to take this opportunity to express my gratitude on behalf of USAID/DR for the great work that you have all accomplished. By establishing SUGEMI you have provided the Government of the Dominican Republic the ability to provide its people with timely access to essential medications. Your work on the rational use of medications and drug list revisions have led to sweeping changes that are saving the state millions of dollars. With accomplishments too numerous to mention here, we recognize that SIAPS has been a critical contributor to the national HIV response and a key USAID/DR implementer. The project staff we have worked with over the past many years have demonstrated an exceptionally high level of commitment and competence. Thank you again for all that you have done.”
– USAID Health Office Director, Jo Jean Elenes, on August 24, 2017
