The document summarizes challenges to accessing essential medicines in Kenya's public health system. It discusses how Kenya's health system is divided into public, private, and faith-based sectors. The public sector faces challenges like stockouts of commonly prescribed medicines, issues in the supply chain, and poor storage conditions. Decentralization of healthcare management to county governments has contributed to financing issues challenging public health facilities. The document analyzes these challenges and provides recommendations to improve access, such as better training for ordering, storing, and prescribing medicines.

1. Access to Essential Medicines in the Kenyan
Public Health System
Boston University School of Public Health | Gloabal Health Culminating Experience
Elizabeth Boyer | December 3, 2015
ABSTRACT
As part of upholding the right to health provided in the constitution, Kenya must ensure access
to essential medicines. Kenya’s health system includes public, private, and faith-based sectors
for health care and medicines, but this analysis focuses on the public sector. The public health
sector has made efforts to improve access such as providing medicines free of charge at health
centers. Despite these efforts, the Kenyan public health sector continues to face challenges in
ensuring access. Challenges include geographic distance patients must travel to reach facilities,
frequent stock outs of commonly prescribed medicines, issues in the supply chain, poor storage
conditions, and irrational use. All of these challenges are analyzed closely to pinpoint areas for
improvement or change. Recommendations, such as providing better trainings in ordering,
storing, and prescribing medicines, are provided. Other solutions to supply chain and stock out
issues are explored as well. Kenya has the potential and drive to improve access to essential
medicines and improve the health its people.
Keywords: Essential medicines, Kenya, supply chain, stock outs, access to medicines

2. Introduction
The government of Kenya viewshealth as a basic human right. One of the most basic, yet
powerfulways to promote health is through medicines. Kenya still faces high death rates from
diseases that can be easily treated by medicines that should be accessible to every citizen. Public
health facilities oftenface stockouts of medications. Privateand faith-based facilities can very
costly,despite higher availability of medicines. Evidencepoints to break downs in the supply chain
as one of the major issues in ensuring availability among several others. If Kenya wants to see
improvement in the health of its citizens, actions must be taken to improve access to essential
medicines. The goal of this paper is to analyze the current situation of medicine accessibility in
Kenya, specifically in the public sector, and provide recommendations on policies and actions to be
taken in order to improve access.
Background
CountryBackground
Kenya is located in eastern sub-Saharan Africa. The World Bank classifies Kenya as a lower-
middle income country.It has a GDP of $60.94 billion in US dollars(1). The country is divided into 8
provinces that have been further divided into 47 newly created counties. These counties were
created under the 2010 Constitution, which initiated the devolution of the country(2).Eachcounty
is an administrative unit, governed by local elected officials.This will be discussed in further detail
below withregards to how it relates to the health system.
The population of Kenya is roughly 44.86 million with approximately 25% living in urban
areas(1,3). The majority of the population is living in rural areas where there is also a high
prevalence of poverty (4).About 42.2% of the population is under the age 15 (3). Kenya has a
maternal mortality rate 400 deaths for every 100,000 live births and the under-five mortality rate
is 71 deaths for every 1,000 live births (3). The life expectancy at birth is 62 years (1).These
indicators all suggest weakness in the Kenyan health system.
TheKenyaHealthSystem
The government of Kenya viewsaccess to healthcare as a basic right. The Kenya Health
Policy Framework(KHPF1994-2010) is the overarching health policy whichaims to “promote and
improve the health status of all Kenyans through the deliberate restructuring of the health sector to
make all health services more effective,accessible, and affordable” (5,6). The only current available
health policy plan is the second National Health Sector Strategic Plan (NHSSP II 2005-2010). The
third NHSSP is currently under development. The NHSSP sets out specific goals for the health sector

3. to focuson based on the country’s current needs. The Kenya Essential Packagefor Health (KEPH),
whichis based on a lifecycleapproach, was first proposed in the NHSSP II2005-2010 (7). The
system focusescare of different age cohortsthrough a six level system. These levels are illustrated
in Figure 1.
Figure 1. The Kenya Essential Package for Health (KEPH)
Public health facilities accountfor 52% of all health facilities, making the government the
leading health provider by a small margin (5). Private,NGO, and faith-based facilities also provide
for a significant portion of the population. In order to encourage more patients to utilize public
health centers and dispensaries, the government of Kenya announced in 2013 the removal of all
users fees at these lowerfacility levels (8). This includes any medicines given at the visits as well.
Additionally, the government also announced in 2013 that all maternal health services would now
be free. Despite such policy changes, inadequate human resources, infrastructure, and finances
have limited the public sector (4). Such struggles in the pubic sector were witnessed first hand
during my evaluation of leveltwo and three health facilities in Southern Kajiado Sub-County of
Kenya this past summer (9). This causes many patients to continue to turn to the private sector,
despite the higher costfor care and medicines. In some cases, patients even opt out of seeking
professional care at all.
Decentralization
As mentioned before, in 2010 a new constitution was approved forKenya, whichdevolveda
wide range of administrative, political, and financial responsibilities to 47 newly created counties
(2). Under this new county system, locally elected administrators and officialswere given control of
these selected functions for their county. One such functionwas the delivery of essential health
services (2). The national government still retains health policy,technical assistance to counties,
and management of national referral health facilities. In addition, the national government is also

4. responsible for funding the counties based on a standardized formula. The counties must budget
and disseminate these funds.
The County Health Management Team (CHMT) is the responsible unit for budgeting and
disseminating funds to the sub-counties whoactively manage health facilities. Complete
management of all public health facilities is the now the responsibility of the county and sub-county
officials. This includes the procurement of medical supplies and medicines. The counties are now in
a critical position for ensuring access to essential medicines at public health facilities. Oftentimes
the funding provided by the national government is not enough to meet the needs of facilities. The
pledged government expenditure on health has not been met overrecent years, whichreduces the
funds available directly to the counties. In a key informant interview with a nursing officerat a sub-
county hospital in Kenya, finances were stressed as one of the key challenges facing management of
public health facilities. (10)
EssentialMedicines
For purposes of clarity,it is important to define essential medicines. The WHOdefines
essential medicines as “those that satisfy the priority health care needs of the population” (11).
These medicines are selected with regard to disease prevalence, evidence on efficacy andsafety,
and comparative cost-effectiveness.The medicines included in an essential medicine list (EML)are
intended to be available in a health system “at all times in adequate amounts, in the appropriate
dosage forms, with assured quality, and at a price the individual and the community can afford”
(11). The Kenyan government developed their first EML in 2003 but it soon became outdated. The
updated EML was developed in 2010 is still the one currently in use. This list was created with
assistance from a WHO consultant in line with the WHOguidelines (12).
The list is broken into thirty-one therapeutic classes of medicines. There is a core list, which
represent the priority needs forthe health-care system. Then there is the complementary list,
presented in italics. These medicines are forpriority diseases forwhich specialized diagnostic or
monitoring facilities and/or specialist medical care, and/or specialist training are needed (12).The
analgesic category of the Kenyan EMLis provided in Appendix I as an example of the framework
and how the complementary list is presented. The EMLincludes information on the lowest levelof
care in whichthe medicine should be used, the therapeutic priority, and the procurement priority
level. The procurement priority is based upon whether the medicine is coreor supplementary. Core
“It was a standard to meet health needs but now they are giving bellow
par…Facilities like this to operate well, you need money.”—Nursing
Officer

5. list items should always be in stockand available, but the supplementary medicines are only
available upon special request. All of this additional information guides procurement, distribution,
and stockmanagement of the medications. In this regard, the EML provides significant benefits to
the health sector and their management of medicines. It also benefits prescribing by making
training for prescribers more focused because there are fewermedicines to on which they need to
be informed. Fewer medicines enables prescribers to focusknowledge just to medicines on the
EML, enabling them to better identify adverse drug reactions as well. The EML also promotes lower
prices by creating more competition and lowering supplies management costs (12).
PharmaceuticalSector of Kenya
The last key piece of background information pertains to how the pharmaceutical sector
functions in Kenya. A comprehensive background wouldbe toodetailed for this analysis, so I will
focuson the relevant components. The Kenya National Pharmaceutical Policy (KNPP),updatedin
2010, is the frameworkfor the pharmaceutical sector (13). Its goal is to provide universal access to
quality pharmaceutical services, essential medicines, and essential health technologies in Kenya (5).
This goal is in fulfillment of the right to health, recognized in the Kenyan constitution.
In order to successfully supply pharmaceuticals within a health system, there needs to be a
strong pharmaceutical sector. Figure 2 was created by MSH as a model forhow the management of
the pharmaceutical sector should work (14).Selection was completed with the creation of the
national EML.Procurement, distribution, and use should all be guided by management support.
National policies and laws should then regulate all of these components.
Figure 2. Components of pharmaceutical management cycle

6. The government of Kenya has a centralized pharmaceutical procurement and distribution
system foressential medicines and medical supplies. The Kenya Medical Supplies Authority
(KEMSA) is the government-owned company responsible forprocuring, storing, and distributing
supplies and medicines to the public sector facilities (15).Procurement is limited to medicines on
the EML and any recently updated standard treatment guidelines. Since devolution, KEMSA is now
competing forthe business of the 47 counties of Kenya. Eachcounty is now responsible forordering
and paying for medicines and health commodities fortheir facilities, rather than the facilities
ordering for themselves. This means that the counties can procure from the company of their
choosing. This has caused KEMSA to adopt a new business model to a competitivemedical logistics
authority rather than a bureaucratic medicines supply agency (15). The majority of counties still
choose to use KEMSA forthe supply of their medications and supplies, which are delivered
quarterly. Table 1, derived from a 2014 case study on KEMSA, depicts some of the major changes to
KEMSA since devolution (15)
Table1. ChangesinKEMSA’soperatingmodel sincedevolution
Function Pre devolutionmodel of
KEMSA
Post devolutionmodel of
KEMSA
Who pays? Ministry of Health paid for
the procurement of
commodities and costs of
warehousing and
distribution
Program drugs (HIV/AIDS,
Malaria, TB, RH) financed
separately
Counties will pay the cost of
the commodities plus a
warehousing and
distribution fee
Program drugs (HIV/AIDS,
Malaria, TB, RH) financed
separately
Who procuresfrom
manufacturer/supplier?
KEMSA
Except select program drugs
KEMSA
Except select program drugs
Choiceofmedicinessupply
agency
All public health facilities
receive supplies from
KEMSA
Counties can choose to
purchase fromKEMSA ad-
hoc, KEMSA under MOU or
from other suppliers e.g.

7. MEDS
Whichproducts? Ministry of Health Ministry of Health, KEMSA,
and counties
Who placesan order? Health facilities in the pull
system since 2010, MOH
before that
Counties place orders on
behalf of all health facilities
in county
Payment terms Erratic payment from MOH
to KEMSA
Counties pay upfront before
receiving supplies or 30 days
credit
Deliveryfrequency Quarterly (monthly to
hospitals)
Quarterly (monthly to
hospitals) in most cases. Part
of agreement between
counties and KEMSA
Transport Privatetransporters
contracted by KEMSA
deliver product to all health
facilities
Privatetransporters
contracted by KEMSA
deliver product to all health
facilities
Counties may choose to
receive supplies at a single
location
On the patient end, medicines are available free of charge at health centers and dispensaries
in the public sector (level twoand three facilities). This is part of the previously mentioned national
policy from 2013 in whichall services at these facility levels would be free and without registration
fees, including medicines (8). There is little data on the impact these free medicines on improving
access since the implementation is so recent. The same nursing officerinterviewed this past
summer indicated that the reality of the situation is stock outs at these facilities remain an issue
due to delays from KEMSA.
“…some times they [KEMSA] delay. They are not so effective….
They don’t deliver in time.” –Nursing Officer (10)

8. While access to free medicines in these lowerlevel facilities is a great program, if they are
unavailable or stockedout, it is not helping patients. They willhave to seek medications elsewhere.
The private and FBHS facilities provide medicines free forchildren fiveyears and under.
Waivers are also in place at these facilities forpatients whocannot affordmedicines. Publicly
procured medicines for priority health programs also are available free of charge. These included
medicines for malaria, HIV/AIDS, TB, and also contraceptives(4). All other medicines in private
pharmacies, private facilities, and at higher level public facilities still require out of pocket payment
and can often be costly,especially for the poorest populations. These are the sources patients are
turning to when they cannot access the free medicines at the clinics and dispensaries. This willbe
explored further in the situation analysis.
Situation Analysis
Despite all of the attempts made by the Kenyan government to improve access to medicines
as part of the right to health, there are still many shortcomings. Studies from2009 to present all
indicate that Kenya still struggles in ensuring the population’s access to essential medicines. When
analyzing access to medicines, geographic accessibility, physical availability,the supply chain,
storage conditions, and rational use are all important aspects to consider. All of these aspects will
be analyzed as we explore the current situation in Kenya with regard to access of essential
medicines. This will help target the problem areas in order to formthe recommendations.
Geographic Accessibility
In this paper, geographic accessibility will refer to the distance patients must travel in order
to access essential medicines. In 2009, twosurveys were conducted on access to essential
medicines in Kenya (4,5). The first was a household survey and the second was a health facility
survey. These surveys captured data from across the entire country and across all socioeconomic
status (SES)levels. In the household survey, the findings indicated that majority of households are
able to access a public health facility within less than an hour (4). As mentioned in the background,
free medicines are only offered in the public health centers and dispensaries, not any public health
facility.The survey found that less than half of the poor and middle-income households could
access one of these facilities within less than one hour. The great distance patients need to travel to
access the free medicines is notable barrier.
Many patients may not feel the distance is worth traveling for free medicines, especially
since stock outs are knownto be an issue. The same household survey found that overall only 32%

9. of surveyed households responded that the closest public health facility usually had the medicines
they needed. In contrast, the survey also found that 70% of households said the closest private
pharmacy usually has the medicines they need. (4) This discrepancy is why so many patients are
still paying for medicines instead of traveling an hour or more with no guarantee of receiving their
needed medicines. The poorest households may have to use most of their monthly income or even
borrow money in order to obtain these medicines at private pharmacies.
The most frequent source of medicines in surveyed households was from NGO providers. It
can be assumed that many patients are turning to NGOfacilities for their medicines. These patients
often travel overan hour to reach these facilities as well, but the higher availability of medicines
incentivizes the great distance. The NGO medicines were also found to be more likely to be kept in a
good container withan appropriate label. The distance remains a barrier, but it appears to be worth
overcoming when availability and quality are assured.
As mentioned in the background, the EML indicates certain medications can only be used at
certain facility levels. Patients whoneed medications only offered in a hospital facechallenges with
geographic distance as well. In order to reach a pubic hospital, 67% of the poorest households and
even 47% of the wealthiest households had to travel overan hour. (4) The travel time toan NGO or
Mission Hospital was similar. These significant distances are of great concernfor obstetric
emergencies which only hospitals are equipped with the medicines to treat.
Availability & Stock Outs
Given the low perception of medicine availability at public health facilities in the household
survey, there must be some sort of availability issue at the facility level. Availability refers to
medicines being in stock at the facilities when the patient needs them. In the facility survey from
2009, 15 basic medicines wereused as indicators to measure availability. Government run health
facilities had a median of 87% availability of these medications. In contrast, faith-based health
service (FBHS) facilities and private pharmacies both had around 93% availability (5). The
question raised here is why do the government facilities have loweravailability of these basic
medicines? The survey also measured availability in the government (KEMSA) warehouse.1 There
was 100% availability of all 15 basic medicines in the KEMSA warehouse (5).This suggests that
there is an issue in the public supply chain and distribution system. This will be more closely
examined in the followingsection.
1 This survey was conducted prior to the decentralization of medicine procurement to the counties and
switch of KEMSA to a competitor rather than the solesource for public facility medications.

10. This lack of availability of basic medicines has negative consequences on the patients
visiting the public facilities. The survey found that in public facilities, 86% of the prescribed
medications were also dispensed to the patients (5).This means that patients have to seek
medications somewhere else and that could mean paying a substantial amount of money. A patient
may spend a day traveling and visiting a health center and then have to go out and seek some of
their prescribed medicines at a private pharmacy where they must pay out of pocket.This whole
scenario creates dissatisfaction withpublic health facilities.
The reason medications are unavailable is typically because of stock-outs.Stock-outs can
happen in all sectors, but tend to last longer in public facilities. The national median for stock-out
duration in public facilities in 2009 was 46 days compared to 13.5 in FBHS facilities (5). Masters et
al. conducted a more recent study in 2012, whichmeasured pharmaceutical availability in Kenya,
Ghana, and Uganda. In this study, in Kenya, health centers were stocked-out of 33% of essential
medicines and dispensaries were stocked out of 39% (16). The results indicated that overall, low-
level public health facilities facedthe highest proportion of drugs stocked-out.The study foundthat
the ruralality of the facility did not have a significant effecton stock outs of essential medicines,
however,where the facility receiveddrugs was significantly associated (16). These findings once
again suggest a problem in the supply chain itself and not necessarily withthe infrastructure or
distance frommain roads.
Moving even closer to the present-day situation in Kenya, in 2014 a study was conducted in
public hospitals in Nakuru County (17). The study measured the availability of essential medicines
but also looked into the most common causes of stockouts. Similar to the other studies, the
researchers found issues withstock outs of essential medicines; primarily antibiotics, anti-malarial
medicines, and analgesics. The study identified four key reasons for the stock-outs: poor
distribution, funding issues, inappropriate selection, and irrational use. Keeping in line with
conclusions drawn from the previously discussed studies, over 90% of the stockouts were
attributed to poor distribution (issues with supply chain). The other three factors, however,were
found as causes for over 50% of the stockouts (17).Many respondents for the survey felt strongly
that they were not allocated enough money from the government to keep essential medicines in
stock.Inappropriate selection and irrational use show issues at the management and policy level.
These factorswill be mentioned again in the recommendations section.

11. Supply Chain
As previously described studies have suggested, there is a need to examine the supply chain.
For the sake of simplifying this analysis, I will just be focusing on the KEMSA supply chain and
storage practices in public facilities. In Kenya there is also MEDS(the faith-based sector warehouse)
and also private manufacturers and distributors. These supply chains also support a large portion
of the population, but evidence from studies indicates greater issues in the public sector, which is
the reason for focusing on it.
KEMSA’s infrastructure consists of two warehouses located in Nairobi and 8 depots
distributed regionally (18).Private transporters contracted by KEMSA make the deliveries to the
facilities. As described in the pharmaceutical sector background, the counties are now responsible
for procuring medicines and commodities for all of their public health facilities. Eventhough
counties have the option to procure from the source of their choice, most still opt to use KEMSA.
Figure 3 depicts the KEMSA supply chain (18). This process map is a useful visualization of the
various steps in the supply chain, but also can help pinpoint areas in the process where issues could
arise.
Figure 3. KEMSA Supply Chain Process Map

12. The first point in the supply chain that couldcontribute to stock outs is the order fromthe
county officials.The county uses the pull system for ordering medicines. This means each facility is
responsible for reporting their medication needs to the county to be ordered quarterly.
Inappropriate requests are often placed as a result of facility staff whoare often untrained in
determining the medication needs of a facility (17).The lack of a threshold forwhen to order more
of a medication also contributes to inadequate requests. All of these issues at the locallevel of the
supply chain result in inadequate requests being placed to the county.The county only has these
requests to inform their order to KEMSA.
Funds may also hold up the process if the county has not allocated enough money in their
budget to procure all the needed medicines and commodities for facilities fromKEMSA. The process
map shows that KEMSA willnot process the order until a payment is made. Those first twosteps of
ordering and payment can make a significant impact on the timeliness and adequacy of the supplies
moving through the rest of the chain.
There are other problematic areas in the system. KEMSA only delivers quarterly, which
increases the importance of accurately forecasting needs. Also, if a facility wereto run out of a
medicine because of higher demand than usual, they must wait until the next quarter to receive
their shipment. Poorroads and transportation couldalso contribute to delayed receipt of
medications and commodities at the more rural/hard-to-reach facilities. Central warehouse level
stock-outsalso may occurif KEMSA were to underestimate needs when procuring. As you can see,
there are many places in this process where problems couldarise, and I have only mentioned a few.
It should also be mentioned, that as nice as the supply chain and KEMSA supply system
looks on paper, it does not always match reality. During a key informant interview with a sub-
county medical director in Kenya, he explained the real situation on the ground in his sub-county.
Despite the way the system is supposed to work,often there are problems. Supplies may be
delivered tothe wrong facility or they may not show up when they are supposed to (19). A key
informant interview with the nursing officerof the same sub-county revealed that delays from
KEMSA are very common despite timely ordering (10). Due to the frequency of stock-outs and
delays, sub-county hospitals are provided withan emergency fund to seek out medications when
they run out prior to the next KEMSA shipment. Toooften these funds are used up because of these
supply chain issues.

13. Storage Conditions
It is also important in any discussion of access to medicines to mention storage conditions.
Storage can refer to how medicines are stored in-transit and at the facilities themselves. Proper
storage of medications is imperative to ensure the quality of the activeingredients. One prime
example of the need forproper storage conditions is oxytocin.Oxytocinis an injectable drug used to
prevent and treat post-partum hemorrhage in mothers giving birth. It is included on the essentials
medicine list and is the WHOdrug of choicefor use during delivery. Oxytocinrequires cold storage,
at around 2-8 degrees Celsius. There are often issues maintaining the cold-chainduring distribution
of oxytocin.There is a form of oxytocinthat can be stored at room temperature (15-30 degrees
Celsius), but hospitals are still required to have the cold storage version of the drug. A study was
done in 2012 of on availability and management of such maternal health medications. The study
found that there was low knowledge of personnel in the public sector of proper storage conditions
for these drugs (14).
Storage conditions are important forall medications as well. The 2009 Health Facility
survey assessed adequacy of storage conditions for medicines. It found that KEMSA warehouses
only met 50% of minimum criteria foradequacy. In public health facilities, the median adequacy
level was 60% forthe storerooms and 62% for the dispensing area (5). These are concerning
figures since poor storage can affectthe quality of medications. The study also found that many
public facilities were storing expired medications. Not only does this pose the risk of a patient
receiving an expired med, but it also indicates waste and potentially poor ordering. There is a clear
need forinterventions to improve the storage of medications.
Rational Use
The final factoraffecting accessibility of medicines we willanalyze is rational use. What is
rational use of medicines? The WHO provides the following definition: "Patients receive
medications appropriate to their clinicalneeds, in doses that meet their ownindividual
requirements, foran adequate period of time, and at the lowest cost to them and their community"
(20). The Ministry of Health has developed National Standard Clinical Guidelines (SCG) and has
recently put out the third edition (17). The purpose of the SCG is to promote rational prescribing
and use of medicines. The issue is weak or nonfunctionalmechanisms to ensure compliance to the
SCGs. Rational use of medicines is essential for reduction of waste and hazards to patients in
addition to achieving desired therapeutic outcomes.

14. In a discussion about improving access to essential medicines, youmay be wondering why
rational use is so important. First, if you recall the cycleof pharmaceutical management, the fourth
component of the cyclewas “use.” This is because appropriate use determines the availability of
medicines for patients. If wasteful prescribing occursat a facility,they may run out of the medicine
for when a patient really needs it. Antibiotics are one such class of medicines that are often over-
prescribed and thus prone to stockouts. In Wangu et al., the authors also cited inappropriate use as
a factor contributing to stockouts at public hospitals in Nakuru County (17). Proper use of
medications cannot be overlookedwhen ensuring the Kenyan population’s access to essential
medicines.
Recommendations
In order to address the issues I have just discussed, I have developed several
recommendations to improve access to essential medicines in Kenya. I have divided my
recommendations into categories that correlate with the fivedifferent topics presented in the
situational analysis. Naturally, not all recommendations are high priority and some are intended as
long-term or future goals. Table 2 highlights and summarizes the high priority recommendations.
Geographic Access
 Increasenumberof dispensariesandhealthcentersinrural areas: This
recommendation is low priority and a longer term-goal. The proportion of the population
whoare further than one hour travel distance from a public health facility is only 10% (4).
While increasing access to health care and medicine should be a priority of the Ministry of
Health, it is understood that human resources and funding are lacking, whichmake this
recommendation difficultto implement in the near future.
 Improveroadsandtransportationto facilities:Improving roads and providing public
means of transportation to public health facilities coulddramatically increase access to
health care and essential medicines. Similar to the previous recommendation, this is low
priority and a long-term intervention. It requires large amounts of money and an
infrastructure capacity building scheme that is difficultto undertake in Kenya. Despite
challenges, looking into the future, this should be a goal of the Government of Kenya and
Ministry of Health.
Availability & Stock Outs
 Providetrainingsonproperorderingandimprovemethods: Sincedevolution and the
transition of ordering medications for facilities to the county level officials,there have been

15. issues with stock-outs because of poor anticipation of facility needs. Trainings for
pharmacists, facility staff, and county officialsshould be provided on how to accurately
quantify the needs of all public facilities in the county.Thresholds should also be set for
each facility level of when a stockis considered low and should be ordered.
Factors such as seasonal health conditions should be factoredinto the estimation process
for quarterly ordering. Certain drugs may only be needed for certain season, whichshould
be factored into the process. For example, during malaria season a greater amount of anti-
malarials should be ordered. Outside of this season, only minimum quantities need to be
kept at facilities. This recommendation willnot only reduce stock outs of facilities but will
also reduce over-ordering and waste due to expired products.
 EncourageUseofLMIS and E-Mobile;ensurecapacityforsystem:Inthe last couple
years, KEMSA has launched and begun implementing its online portal for ordering
medicines and commodities, the Logistics Management and Information System (LMIS).
This has been created with the purposes of easing the ordering process forthe counties,
reducing paper-based forms, and speeding up the process. The manual ordering process
using paper forms could take weeks or months forKEMSA to receivethe form. The
turnaround time now has been reduced from an average of fourweeks to four days,
depending on the order. LMIS will even send an SMS message when the order has been sent
out so the county officialsare informed. It is free of charge to all clients and KEMSA is also
providing free trainings forcounty health officials.Only three counties have fully embraced
the LMIS so far. More counties should be encouraged to do so. (21)
In addition, counties should ensure capability forusing this system. This would mean
equipping facilities with a computer, laptop, or tablet. Internet access also needs to be
ensured. KEMSA has also just created an app to go along with the LMIS system, called
KEMSA E-mobile. This can be used by health facility workers and County Health
Management Teams to report consumption, order medicines, and provide data for
stakeholders. In situations where a computer may not be feasible at a facility,staff can use
any GSM device (even low end phones) to place orders and track past consumption.
Internet access or payment/stipend forphone data would need to be ensure for the mobile
app as well. (22) This is very feasible and has potential to be highly effectivein improving
access to medicines by improving availability.
 Encouragecountiesto consider othermedicinesupplyagenciesbesidesKEMSA;look
forqualitydistributionandlowerprices: Thecounties should embrace the new

16. competitive market in medicine supply that has appeared as a result of devolution. Many
counties still use KEMSA out of familiarity despite the reputation of poor performance. If a
county continues to make effortson their end to reduce stock outs and continues to see
issues because of delays from KEMSA, then other medicine suppliers should be considered.
There could potentially be better price options and higher quality servicefrom other
distributors. Additionally, the increased competition will drive downcosts in the long run
and motivate KEMSA and other supply agencies to improve the quality of their service.
Supply Chain
 Appropriate andtimelyordering andpayments:This recommendation is very
straightforward and can be high priority since it is a simple solution that can make a big
difference. Counties need to ensure that they are getting their orders and payments to
KEMSA (or other supply agency) in a timely fashion to ensure the facilities receive
medicines before they run out. This is the first step in the supply chain and a delay in this
step can cause a delay the whole process. This requires each facility to accurately quantify
their needs and send it to the sub-county health management team in a timely fashion. The
sub-county officialsneed to compile all facility orders to send on the county pharmacist.
This pharmacist can only send an order to KEMSA once all orders have been received.
Timely submission by all parties is critical to placing a timely order for the whole county.
The new LMIS and E-Mobile systems will hopefully cut down time by using the internet to
send orders rather than delivering paper forms, whichcould take days or weeks even. The
trainings recommended previously would also help ensure the orders are accurate in
addition to timely. This is a high priority and highly feasible recommendation.
 Promotepublic-privatedialogueandexchangeofbestpracticeideas:This
recommendation has been considered high priority because of the significant impact it
could make on improving the supply chain. Public and private sector supply chains both
have their strengths and weaknesses. KEMSA has a strong and award-winning logistics
management information system (LMIS).The private sector has a farsuperior distribution
system. If the two sectors could participate in dialogues and exchanges of ideas, each could
benefit from the others strengths to improve the supply chain and access tomedicines.
Workshops could be sponsored to bring the twosectors together and discuss wayseach can
improve and learn fromeach other. (18)
 FlexibilityinKEMSA’sdeliveryfrequency:Currently,KEMSA delivers quarterly withthe
exception of hospitals whoreceive monthly deliveries. Some counties may benefit from

17. more frequent deliveries, especially since outbreaks and emergency situations cannot be
predicted. Others may wish to remain on a quarterly delivery system. If KEMSA were to
offerflexible deliveries, stock-outs couldbe reduced and the supply chain wouldbe less
burdened at the beginning of each quarter. KEMSA would also be offering a service that will
increase customer support and aid them in competition for counties’ business. (15)
Storage Conditions
 Properstaffat all facilities: Eachfacility should be staffed with a well-trained pharmacist
or pharmacy technician to manage the stockcards and storage of facility medicines. Since
human resources is a nationwide struggle, this recommendation has been given low priority
since other staff members can receivetraining on this matter. As a future goal, better
staffing is strongly recommended.
 Propertraininginstorageconditionsformedicines:Allfacility staff,including those
with some sort of pharmacy training, should be required to undergo a training session on
proper storage of medicines. This training should include proper storage of uterotonics
such as oxytocinand ergometrine whichneed to be stored cold (2-8 degrees Celsius). These
trainings are high priority recommendations since proper storage can have a significant
impact on the quality and potency of many medicines.
 Ensurefacilitieshaveproperspaceforstorageanddispensingof medicines:In
addition to proper training, all facilities should be evaluated and, if necessary, equipped
with proper space forstorage and the dispensing of medicines. This is a low priority
recommendation since the training of staff is a higher priority. This recommendation is still
a measure the MOH should ensure all facilities have to protect the quality of medicines and
ensure the safe dispensing of them.
Rational Use
 Staff trainingsonStandardClinical Guidelines (SCGs): Themedical staff at each facility
should be trained on the SCGs and each facility should be supplied with a copy of it. This will
promote rational use of medicines. Use of SCGs will also reduce over-prescribing or wrongly
prescribing medications to patients. Better prescribing and use of medicines can also
reduce likelihood of stock-outsof commonly or over-used medicines. This should be a
priority recommendation as it is easy to implement and can have a significant impact on
availability of medicines and patient outcomes.
 Medicines ComplianceOfficerforeachcounty:Atthe county level, there should be
position fora Medicines Compliance Officer.This individual will be responsible for

18. monitoring facilities forrational use of medicine and adherence to the SCGs. This individual
will also coordinate the MTCs that were recommended for each hospital previously.This
will provide better accountability for proper management and implementation of best
practices in regards to essential medicines.
Table2. Highpriorityrecommendations/interventions
Recommendation Expectedoutcomes
Providetrainingsonproperorderingand
improveordering methods
 Reduce stock-outs because of appropriate
amounts of medication being ordered and
ordering before stocks get too low
 Reduce waste and risk of medication expiration
by minimizing over-ordering of less used drugs
 Seasonal conditions are well supplied during
appropriate season and not over supplied during
off-season
EncourageUseofLMIS and E-Mobile;
ensurecapacityforsystem
 Reduction in errors and misread forms
 More efficientordering with quicker turnaround
from KEMSA
 Better quantificationand appropriate stocks;
stockouts reduced
 Better tracking of past consumption to better
inform future
 More accurate procurement by KEMSA
Promoteappropriateandtimely
orderingandpaymentby counties
 Reduce delays in medicine deliveries/supply
chain
Encouragecountiesto considerother
medicinesupplyagenciesbesides
KEMSA;lookforqualitydistributionand
lowerprices
 Encourage competitive market
 Reduction of prices
 Improved distribution/supply chains
 Distributors encouraged to step up quality of
supply chain
Promotepublic-privatedialogueand
exchangeofbest practiceideas;can be
achievedthroughsponsoredworkshops
 Privatesector can benefit fromKEMSA’s award-
winning logistics management information
system (LMIS)

19.  KEMSA can benefit fromprivate sector’s superior
distribution systems
 Reduce stock-outs; increase availability of
essential medicines
 Quality of medicines maintained in supply chain
Trainingsinproperstorageof
medicationsfor facilitystaff
 Quality of medicines preserved
 Cold medicines (oxytocin) properly stored;
maintain potency
 Increase knowledgeof proper medicine storage
by all facility staff (not just pharmacists)
TrainingonuseofStandardClinical
Guidelines(SCG);makeSCG availableat
all facilitiesto encourageusebystaff
 Reduction of irrational use and prescribing
 Proper medicines fortreatment dispensed to
patients; improved health outcomes for patients
 Improved satisfaction by patients
 Reduction in stock-outsdue to reduction in over-
prescribing commonly stocked-out medicines
Stakeholder Analysis
In order to understand how the recommendations will affectdifferent constituencies, I have
completed a stakeholder analysis. Due to the number of recommendations provided, I have chosen
only to include the high priority recommendations in this analysis. The stakeholders assessed
include patients, public facility staff,private sector distributors, KEMSA officials,county officials,
and government officials.The arguments of each constituent was anticipated and addressed.
Factors such as cost and feasibility were also taken into consideration. Table 3 provides a
comprehensive summary of the stakeholder analysis conducted.
Conclusion
In the 2010 Constitution, Kenya commits to protecting the right to health. Part of
this commitment is ensuring access to essential medicines. The public sector has been
struggling to meet this goal. It has gained a reputation of unreliable availability of
medicines and poor quality due to improper storage. Despite free medicines at lower level
facilities, many patients continue to choose other sources because of such poor

20. perceptions. The recommendations in this paper aim to increase access to quality essential
medicines in Kenya’s public facilities by strengthening the supply chain, reducing stock
outs, improving storage conditions, and encouraging rational use. When patients can access
medicines, unnecessary deaths are prevented and lives are improved. Kenya has great
potential to do just that and improve the quality of its health system by ensuring every
citizen has access to essential medicines.

21. Table 3. Stakeholder Analysis
STAKEHOLDER
Providetrainings
onproper
orderingand
improve
ordering
methods
Encourage
Use ofLMIS
and E-Mobile;
ensure
capacityfor
system
Promote
timely
orderingand
payment by
counties
Encourage
countiesto
considerother
medicine
supply
agencies
besidesKEMSA
Promotepublic-
privatedialogue
and exchangeof
best practice
ideas
Trainingsin
proper
storageof
medications
forfacility
staff
Trainingon
use of
Standard
Clinical
Guidelines
(SCG)
Patients SupportALL: The patients in Kenya would support all sixof the priority recommendations. The reason for the support is because all
recommendations would improve availability to essential medicines, require no cost tot hem, and also improve over all quality of medications and
treatment provided to the patients. They would likely have increase satisfaction with the public health system
PublicFacility
Staff
Support:Increased
knowledge on how
to order medicines,
reduces stock outs,
increases
availability of meds
for patients
Support:Makes
ordering easier,
reduces
paperwork,
decreases delays
Mixed:this
would reduce
delays and stock
outs, but with
their current
work load and
understaffing,
staff may find this
challenging
Mixed:Wants to
ensure reliable
supply of quality
medicines from
any source, but is
familiar with
KEMSA already
Support:Would
improve system; can
benefit from
exchange; will help
improve medicine
availability in long
run
Support:will
increase their
knowledge and
skills;will
ensure
medicines retain
quality and treat
patients
Support:will
increase their
expertise and
knowledge in
prescribing, will
also make
prescribing more
simple; will
result in better
patient
outcomes when
treated properly;
reduce stock
outs from not
over-using
certain meds
PrivateSector
Distributors
Support:More
accurate orders will
be placed; assists in
accurate
Oppose:This
system makes
KEMSA more
appealing,
N/A Support:Would
provide
opportunity to
Mixed:The private
sector may be
hesitant to work
with their
Support:
distributed
medicines will
retain their
Support:
medicines will
be rationally
prescribed and

22. procurement
calculations
drawing away
potential clients
compete for
more business
and increase
client base
competitor, but will
acknowledge they
can reap great
benefits from these
exchanges as well as
foster better
relationships with
potential clients
(county
governments)
quality; reduce
waste of
medicines
improperly
stored and no
longer potent
will have better
patient
outcomes; will
reduce stock
outs and
improve
perception of
distributor
KEMSA Support: More
accurate orders will
be placed; assists in
accurate
procurement
calculations
Support:They
developed this
tool themselves;
draws in more
customer;
increases their
efficiency, allows
them to make
better
procurement
estimates
Support:orders
would reach
KEMSA in timely
manner so they
can then be
distributed in
timely manner as
well; keeps
system running
smoothly
Oppose:This
would be taking
customers away
and reducing
their business
Mixed:KEMSA will
also be hesitant
about working with
a competitor and
sharing their ideas,
but they can reap
many benefits from
the exchange as well
that will improve
the efficiency of
their system
Support:
medicines
delivered will
remain active
and help patient;
improves
satisfaction with
KEMSA when
medicines
“work”; reduce
waste of ruined
drugs
Support:
medicines will
be rationally
prescribed and
will have better
patient
outcomes; will
reduce stock
outs and
improve
perception of
KEMSA
CountyOfficials Support:orders
placed are more
accurate; more
accurate
consumption
records; less stock
outs; more patients
accessing
medicines; sufficient
medicines during
seasonal outbreaks
Support:Makes
ordering easier,
reduces
paperwork,
reduces wait
time and delays,
increases
accuracy of
orders, better
coordinates all
facilities in
county
Mixed: Similar to
the staff, this
would reduce
delays and allow
them to get in
orders to KEMSA
in time to get
order before
stock outs; staff
and workload
constraints may
make this
Mixed: Wants to
ensure reliable
supply of quality
medicines for the
best prices from
whatever source
that may be, but
is already familiar
with KEMSA and
the ordering
system
Support:
Collaboration and
exchange between
the two sectors will
serve to strengthen
both, increasing the
efficiency and
quality of medicine
and commodity
supply; as both
improve,
competition may
Support:
Medications that
county
purchased will
retain their
potency and
effectiveness;
better patient
outcomes; better
access to
effective
medicines; more
Support:
Medications that
county
purchased will
be rationally
used; reduced
stock outs from
over-use of
certain
medications;
better patient
outcomes as a

23. recommendation
seem like added
pressure; LMIS
should assist
increase and prices
may in turn
decrease
knowledgeable
staff
result of proper
prescribing
Government
Officials
Support:reduction
of stock outs,
increased
availability of
medicines; more
efficient system
Support:
Strengthens the
public health
system by
making public
supply chain
more efficient;
increase
medicine
accessibility
Support:Would
reduce delays and
stock outs; overall
availability of
medicines would
increase; system
will be more
efficient
Mixed: Wants to
support KEMSA &
public sector; in
support of any
method to lower
costs spent of
medicines
Support:Both
sectors can benefit
from each others
strengths; this will
improve access to
medicines in both
sectors improving
the health of the
population as a
whole
Support:more
knowledgeable
health
workforce;
government
funded
medicines retain
their potency
and
effectiveness;
better patient
outcomes,
increased
population
health
Support:
Increased
rational use of
EML medicines;
reduced stock
outs from over
use of certain
meds; better
patient
outcomes and
improved
population
health from
appropriate
prescribing

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53

27. Appendices
Appendix I. Sample of Kenya’s 2010 EML
Acronym/Coding Key:
LOU (Level of Use): Level 1-6 based on KEPH Classification. The level indicated against
each medicine represents the lowest level where the medicine is expected to be
distributed, prescribed, and dispensed.
VEN (Therapeutic Priority): V=vital, E=essential, N=non-essential
AB(Procurement Priority):
A= Core List: routine items which should be always stocked & available
B= Supplementary List: non-routine items, not routinely stocked and only available
upon special request through the established requisition process
# Drug Dose-form Size/
Strength
LOU VEN AB
2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES
(NSAIMs), MEDICINES USED TO TREAT GOUT, AND DISEASE MODIFYING AGENTS IN
RHEUMATOID DISORDERS (DMARTDs)
2.1 Non-Opioids and Non-Steroidal Anti-Inflammatory Medicines (NSAIMs)
2.1.1 Aspirin Tablet 300mg 1 V A
2.1.2 Diclofenac a) Injection* 25mg/ml in
3ml
ampoule
4 V A
*for restricted use only in sickle-cell crisis & severe pain in
patients who cannot swallow
b) Suppository 100mg 4 E A
2.1.3 Ibuprofen a) Oral liquid 100mg/5ml 2 V A
b) Tablet 200mg 1 V A
2.1.4 Paracetamol a) Oral liquid 125mg/5ml 1 V A
b) Suppository 60mg 2 E B
c) Suppository 125mg 2 E B
d) Tablet 500mg 1 V A
2.2 Opioid Analgesics
2.2.1 Codeine Tablet 30mg
(phosph.)
4 E A
2.2.2 Morphine a) Injection 10mg/ml
(HCl or
sulphate) in
1 ml
ampoule
4 V A
b) Oral liquid 10mg/5ml
(sulphate)
4 V A
c) Tablet, 60mg 4 V A

28. prolonged
release (PR)
(sulphate)
2.3 Medicines Used to Treat Gout
2.3.1 Allopurinol Tablet 100mg 4 E A
2.4 Disease Modifying Agents Used in Rheumatoid Disorders (DMARDs)
2.4.1 Methotrexate Tablet 2.5mg
(sodium
salt)
4 E A
Complementary List
2.4.2 Azathioprine Tablet 50mg 4 E A
2.4.3 Chloroquine Tablet 150mg
(phosphate
or sulphate)
4 E A
2.4.4 Sulfasalazine Tablet 500mg 4 E A