In Kenya, County level health systems continue to face challenges that have far reaching effects on citizen’s access to essential health services . Health sector remains a major beneficiary of the national and county budgets, yet there remains critical gaps in the pharmaceutical supply chain which continue to pose significant threats to the access of healthcare services. The purpose of this study was to critically analyse county government procurement procedures (using Kakamega as a case County) with the intent of mapping the direct effect of lapses in procurement systems on the supply and adequacy of pharmaceuticals, and suggest actions that will contribute to improvements in the supply chain.

1. SUMMARY OF
STUDY FINDINGSDEEP DIVE ON THE IMPACT OF GOVERNMENT PROCUREMENT
PROCEDURES ON ACCESS TO PHARMACEUTICALS
OMONDI OTIENO, MPH

2. PURPOSE OF STUDY
Understand the effect of lapses
in procurement systems on
access to health services;
Suggest actions that can
contribute to improvements in
the quality and access to basic
health services.
Highlight Contextual issues that
have an effect on the adequacy
of (non-) pharmaceuticals

3. Examine
challenges
faced by health
facilities in
Kakamega
Propose simplified
health procurement
procedure guide for
effective procurement
and disbursement of
health supplies
Analyze
procurements and
disbursement
specific - and
related - policies
and legislations
Analyze actual
health expenditure
on Pharmaceuticals
SPECIFIC STUDY OBJECTIVES

4. 01
02
03
04
05
06
Key Informant Interviews
Desk Review
Inception & Planning
Rapid Health
Systems Budget
Review
Focused Group Discussions
Validation
STUDY PATHWAY

5. THE CONTEXT

6. IFMIS
Governments official payment mechanism
whose purpose is to improve
accountability and efficacy in the
payment for public goods and services
Devolution
Health Services devolved to counties to
create a robust health system that is
responsive to the unique needs of
populations
Health Governance
The management of various components
of health care.
Citizen Participation
Anchors preventive health initiatives and
drives uptake of clinical services
.
OPERATIONAL
ENVIRONMENT
National Health Act
Prescribes the architecture of
healthcare in Kenya
1
2
3
4
5

7. NATIONAL GOVERNMENT
National referral health facilities
Health Policy
COUNTY GOVERNMENTS
- County health facilities and
pharmacies;
- Ambulance services;
- Promotion of primary health care;
- Licensing and control of undertakings
that sell food to the public;
- Veterinary services (excluding
regulation of the profession);
- Cemeteries, funeral parlours and
crematoria; and
- Refuse removal, refuse dumps and
solid waste disposal.
Functionsareeither;exclusive,concurrentorresidual
DISTRIBUTION OF FUNCTIONS

8. Population
estimated at
2,028,324
Poverty level
of 57%
Size 3,050
square Km, 12
sub-counties;
Pop 17.4% under 5;
26.3% child-bearing
women; 47.1%
under 15, and 4.7%
over 60.
FACTS & FIGURES

9. 176,247
111,574
177,080
138,298
115,677
113,429
154,481
161,977
123,627
151,591
226,743
184,579
180,709
114,398
181,563
141,799
118,606
116,301
158,391
166,078
126,756
155,428
232,484
189,252
185,284
117,294
186,160
145,388
121,608
119,245
162,401
170,282
129,965
159,363
238,369
194,043
189,974
120,263
190,872
149,069
124,687
122,264
166,512
174,593
133,255
163,397
244,403
198,955
194,783
123,308
195,704
152,843
127,843
125,359
170,728
179,012
136,629
197,534
250,590
203,991
S H INY A LU
MUMIA S E A S T
LURA MBI
LIK UY A NI
IK OLOMA NI
K H W IS E RO
BUT E RE
MAT UNGU
MUMIA S W E S T
NA VA K H OLO
MA LA VA
LUGA RI
2013 2014 2015 2016 2017
Graph: Population by Sub-County
Source: Kakamega County CIDP

10. Indicator World National Western
Life expectancy at
birth (years)
59.7 58.9 48
annual deaths (per
1,000 persons) –
Crude mortality
10.54 unknown 12.9
neonatal Mortality rate
(per 1,000 births)
26.7 27.8 28
infant Mortality rate
(per 1,000 births)
26 52 65
under 5 Mortality rate
(per 1,000 births)
29 74 121
Maternal Mortality
rate (per 100,000
births)
95 488 880
adult Mortality rate
(per 100,000 births)
319 5.8%(F), 339
Crude birth rate (per
1,000 population)
37.4 34.8 38
SITUATION OF HEALTHCARE

11. Causes and Risk Factors for MORBIDITY Causes and Risk Factors for MORTALITY
# Condition Risk Factors # Condition Risk Factors
1 Malaria
Exposure to infected
vectors
1 Malaria
Inappropriate and late
medical attention
2
Other diseases of
the respiratory
system
Indoor air pollution 2 Pneumonia
Inappropriate and late
medical attention
3
Disease of the
skins including
wounds
Childhood & maternal
malnutrition
3 Diarrhoea Dehydration
4 Diarrhoea
Unsafe water,
sanitation &hygiene
4 Anaemia
Inappropriate and late
medical attention
5
Accidents–
fractures, injuries
etc
Reckless driving and
driving under
influence
5
abnormal clinical
and lab findings
Misdiagnosis
MORTALITY & MORBIDITY

12. Type of health facility # Percentage
County hospital 1 0.4%
Mission/NGO hospitals 9 3.6%
Private hospitals 1 0.4%
Nursing homes 8 3.6%
Public health centres 27 10.8%
Private health centres 1 0.4%
Public dispensaries 66 26.3%
Private dispensaries 31 12.4%
Private clinics 107 42.6%
Total 251 100%
HEALTHCARE INFRASTRUCTURE

13. • General Staff shortage across all cadres;
• 51% of population not within 5km of health facilities;
• Basic Equipment in need of maintenance; need for critical inputs like
microscopes, weighing scales, etc.
• Facilities sparsely located, with inadequate equipment and HR;
• Supply of medicines and medical products inconsistent
ACCESS TO HEALTH SERVICES

14. ▪ General Staff shortage across all cadres;
▪ 51% of population not within 5km of health
facilities;
▪ Basic Equipment in need of maintenance;
need for critical inputs like microscopes,
weighing scales, etc.
▪ Facilities sparsely located, with inadequate
equipment and HR;
▪ Supply of medicines and medical products
inconsistent
ACCESS TO
HEALTH
SERVICES

15. THE FINDINGS

16. • Absence of definite government guidelines on proportional allocations to the
health sector;
• Poorly managed transfer of functions and contested mandates;
• Low absorption capacity of county governments;
• Poor or weak oversight institutions despite the high level of fiscal autonomy;
• Irregular and unpredictable transfers from the national Treasury;
• Challenges associated with the performance of IFMIS
• Weak citizen participation in the budgeting and planning process, and;
• Low capacity for health procurement
DEVOLUTION

17. BUDGETING
Quantification&
Projections
FACILITY
Orders Generated
SUB COUNTY
Rationalization and Filtration
COUNTY PHARMACIST
Budget Compliance, alignment
with essential medicines list, and
rationalization of quantities
THE LMIS
Computation of rationalised
orders
REQUISITION
Generated by the LMIS and
signed by the County
Procurement Officer, Chief
Officer Health, The County
Pharmacist, and the Accountant
LPO
Raised and submitted to
KEMSA/MEDS
DELIVERY
Product Verification
PAYMENT
CREDIT NOTE
In the event of discrepancies
with LPO
THE PROCUREMENT SYSTEM

18. Process in accordance with good practice but there are gaps in
practice;
▪ Delays in quarterly dispatches leading to stock outs – sometimes of up
to six months;
▪ Haphazard increases in number of health facilities – resources
stretched thin
▪ Most facilities lack inadequate storage facilities limiting the amount of
medicines that can be procured at once.
▪ Low frequency of routine supervision and Spot checks
▪ Weak community participation… although health committees are in
place, their usefulness not apparent.

19. • Based on the County’s expenditure projections, the county health sector
would annually require an average of KES 971,796,992 for
Pharmaceutical Supplies and KES 95,876,509 for non-pharmaceutical
supplies.
• In FY 2016/17, the budget deficit on medicines and medical products was
53% which was way higher than the national average deficit of 46.2%
• Health budget has increased in absolute terms but decreased as percentage
of total county budget - from 25% in FY 2013/14 to 22% to FY 2014/15
• Per capita expenditure on health was $29.7, lower than WHO
recommended $34.
THE COUNTY HEALTH BUDGET

20. Health Care Functions 2013/14(KSh) 2014/15(KSh) % Change
Capital Formation 1,639,393,838 522,288,487 -68.1%
Governance, Health System and Financing
Administration
320,813,294 505,987,611 57.7%
Inpatient Curative Care 611,789,217 1,258,482,364 105.7%
Outpatient Curative Care 1,125,799,841 1,942,550,296 72.5%
Pharmaceuticals and Non-pharmaceuticals 261,622,436 289,194,639 10.5%
Preventive Care 531,919,312 644,593,230 21.2%
Grand Total 4,491,337,937 5,163,096,628 15.0%
(THE) BY FUNCTIONS

21. 0 500 1,000 1,500 2,000 2,500
Capital Formation
Governance ,and Health System and Financing Administration
Inpatient Curative Care
Outpatient Curative Care
Pharmaceuticals and Non-pharmaceuticals
Preventive Care
Millions
2014/15(KSh) 2013/14(KSh)

22. THE RECOMMENDATIONS

23. 1. Increase in Budget Allocation to
Pharmaceuticals
An average deficit of 53% in the
quantities of medicines required
means even with consistent
dispatches to facilities, there would
still be rampant instances of stock
outs. The county government needs to
purpose to progressively reduce this
deficit.

24. 2. Additional Pharmaceutical Personnel
There is an inadequacy of pharmacists and pharm-
techs yet this is a critical factor in the verification,
dispensing and ordering for supplies. While the
County government continues to mobilize resources
to hire additional personnel, there should be
deliberate efforts to conduct CMEs and OJTs for
respective staff.

25. 3. Improvements in the Procurement Process
It is possible for the county’s financial structure
to consider decentralizing procurement of
medicines to the department without losing
oversight authority. The other possibility would
be to restructure the cycle of procurement from
a period of 3 months (quarterly) to 6 months,
to attempt to address the delays caused by a
long procurement process.

26. 4. Investment in the Storage Infrastructure
For elements a, b and c above to be
effective, it is imperative that the county
government and partners support the
improvement of storage facilities at the sub-
county for the start but eventually also for the
peripheral facilities.

27. 5. Strengthen Monitoring & Spot Checks
The commodity security technical working
group and the County and Sub-County
Health management teams need to be
supported to conduct regular spot checks
and to intensify backstopping to all health
facilities. This has been documented to be
one of the most effective ways of
managing possibilities of pilferage of
medicines at facility level.
Consider an Information management
system for pharmaceuticals

28. 6. Focusting and Quantification
(F&Q)
In addition to the budget for
epidemiological emergencies, there is
need for accurate and regular
(annual/bi-annual) medical supply
projections to inform timely
replenishment of supplies. Accurate
projections ensure suitable
prioritization, and facilitates evidence
based budgeting.

29. 7. Community Participation
There is also need for a grassroots driven
Community Health Technical Working Group
(CHTWG) to facilitate continuous collaboration
between the communities and the county
government. This CHTWG can also serve to
support the processes by which Facility
Management Committees are identified, and
subsequently hold them accountable. On its
part, the county government should be ready to
incorporate the views of the community
representatives, and stakeholders in the
budgeting process so as to level their
expectations and harness their resources.

30. In suggesting an alternative procurement model,
the fundamental questions would often be; what
are the gaps in the existing model? What
improvements should be made? And who
should take what role in the process?
With these questions in mind, it is the opinion of
this study that the procurement system for
pharmaceuticals and non-pharms has gaps that
could easily be addressed through a
combination of policy level engagements,
investments in the supply chain, and
intensified involvement of stakeholders
(including communities) – subsequently
contributing to improvements in the mobilization
and management of health resources.
IN CONCLUSION…..

31. Discussions….