Recent studies in Tanzania reveal a tension between the philanthropic aims of international initiatives and the difficulty of ensuring that those least able to pay receive free treatment Maureen Mackintosh
In recent years, private philanthropists and rich-country governments have been pouring funding into the purchase of medicines and other relevant supplies for low-income countries’ populations facing HIV/AIDS, tuberculosis (TB) and malaria. This welcome financial effort has had a major impact in increasing access by low-income populations to essential prevention, diagnosis and medication for these diseases, especially HIV/AIDS. Development assistance for health quadrupled between 1990 and 2007. Access to anti-retroviral drugs in low and middle income countries increased tenfold in the six years to 2007 (to 3 million people), while detection rates of TB and the reach of malaria control programmes also grew.
These international funds are, however, being poured into national health systems, many of which were subject to another major international intervention in the 1990s: liberalisation and deregulation.
Many of the poorest people in low-income countries – and in some middle-income countries too, including India – struggle to gain access to essential medicines and treatment for illness. This is because they have to pay with cash from their own pockets in health systems that are commercialised but unregulated. The poorer the country, the more likely that health care is sold in this way. In Africa and much of South Asia, low-income citizens suffer from substandard medicines, inappropriate, unnecessary or incomplete treatments, excess ill health and mortality, drug-resistant disease, exclusion from treatment and further impoverishment from the struggle to pay.
There are dangers in a policy of bringing large amounts of additional medicines into health systems of this sort. People may not be able to afford the medicines, or they may be used inappropriately and resistance may rise. The international donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, have furthermore focused their criteria for success on outcomes, so that they monitor the numbers in treatment as a result of their funding. Consequently, unregulated commercialized health systems have been found to be an impediment to success.
In reaction, the large funding bodies have been initiating innovations in ‘supply chains’ – a phrase now widely used to refer to the often tortuous paths taken by essential medicines from the manufacturer to, for example, people in need of medicines in Tanzania’s rural areas. Clearly, in deregulated and impoverished health systems, control of this supply chain is difficult. Funding bodies look for control and monitoring to try to ensure quality of, and access to, the products they fund. A recent study of access to medicines in rural mainland Tanzania allows us to look ‘upwards’, from the low-income consumers’ point of view, to see what has been happening to these supply chains – and to consider whether innovations have increased access to proper and timely treatment.
Several innovations in supply chains can be traced. International supplies of HIV/AIDS and TB drugs, purchased through large aid-funded international tenders, are now frequently supplied to patients free-at-point-of-use. In Tanzania, this distinguishes those treatments sharply from the rest of the cash-based health system, and the effect has been greatly to increase access to prescription-based treatment. This is clearly desirable. Access to treatment free-at-point-of-use reduces inequality by moving health systems towards response to need rather than market demand. But this ‘supply chain management’ model is expensive and highly subsidised, and its sustainability is widely seen as problematic.
In Tanzania, the health facilities in the public and NGO sectors (including faith-based facilities) largely buy their medicines from a large public sector wholesaler or from a couple of small NGO wholesalers.
These facilities generally require payment for medicines, and in practice often exclude the poorest. Furthermore, although the public and NGO wholesalers have a good reputation for quality control, public dispensaries often lack key drugs, so many people go there for advice but then buy their medicines in private drug shops staffed by largely untrained sales assistants.
The Tanzanian private market (which delivers about half the essential medicines available in the country) buys both imported and locally-produced medicines but without a quality control capability.
National regulatory control has improved considerably in recent years, but there are continuing problems of quality. The private market is also characterised by exclusion and by a severe problem of under- dosing: the sale of part-doses of required medicines is endemic and a major cause of rising anti-microbial resistance.
Two innovations have influenced, or promise to influence, both the public/NGO and the private supply chains. One is locally driven: local production of medicines has risen as the Tanzanian pharmaceutical industry has been re-established and upgraded, encouraged by public and NGO procurement procedures. The public wholesaler gives a 15 percent price preference to local producers when assessing tenders, and both public and NGO wholesalers can select suppliers and undertake their own quality control; they are not constrained by WHO or Global Fund procurement rules outside the international funding for HIV/AIDS, TB and malaria. The local purchase of other essential medicines through this supply chain has thus been linked to the upgrading of local industrial capabilities and employment in the production of basic medicines.
An international policy with supply chain implications, now at the initiation stage, focuses on malaria. This applies a subsidy for artemisinin combination therapies (ACTs) with the intention of reducing the prices to consumers of the medicines that WHO now recommends as first line treatment for malaria, and that Tanzania has adopted. The subsidy is to be paid to selected manufacturers, mainly in India and China, reducing the wholesale price of ACTs to a level at which they can compete with the price of older anti-malaria medicines. The subsidised medicines will feed into both the public/NGO and private market supply chains.
Looked at from the point of view of low-income rural Tanzanian consumers, supply chain policy is thus something of a muddle – and one that reflects an underlying confusion in international health policy towards low-income health care.
Since lack of access to medicines is a major driver of inequality in much of low-income Africa, and lack of access drives up morbidity and mortality, we should evaluate supply chain initiatives on their impact on access and inequity. This suggests the following conclusions. First, if supply chains for essential medicines depend on a market exchange relationship between producers and consumers, then they cannot deliver egalitarian and appropriate treatment for illness. Therefore supply chain and health system innovations should be judged on the proportion of paid-at-point-of-purchase medicines: the smaller, the better.
Secondly, if innovative supply chain technology relies heavily on external expertise and funding, then this means that it is hard to sustain innovation as part of the local health system. Therefore managed supply chain innovations should be judged on cost-per patient, and on the extent to which they can be scaled up sustainably from individual health interventions to address wider population health needs.
It may be important to ensure that supply chain innovations develop the capabilities of manufacturers able to supply local needs. Sustainable innovation in African health systems could rely in the future more on innovation in terms of local African industrial capabilities and less on massive subsidies for imports. Indeed the Tanzanian linking of health policy tools – such as local procurement – with industrial policies such as those facilitating joint ventures suggests a distinctive and potentially important way forward for supply chains and health systems alike.
