Enhancing the health supply chain for non-communicable diseases management in Rwanda: A qualitative exploration of the perceptions from policy implementers.

doi:10.21203/rs.3.rs-3225709/v1

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Research Article

Enhancing the health supply chain for non-communicable diseases management in Rwanda: A qualitative exploration of the perceptions from policy implementers.

https://doi.org/10.21203/rs.3.rs-3225709/v1

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Background

Efficient health supply chain management contributes significantly to the accessibility of medicines. Low and Middle-Income Countries (LMICs) face challenges in maintaining an uninterrupted health supply chain of health products including non-communicable diseases (NCDs) medicines and nutrition products where stock-outs and shortages are evident. This study aimed to gather perspectives of policy implementers on the supply chain of NCDs medicines and nutrition products in Rwanda.

Methodology

An observational cross-sectional study collecting qualitative data was structured. Purposive sampling was used to recruit 51 individuals involved in the supply chain of NCDs medicines at different levels including central institutions, peripheral level, and hospital level. All interviews were in English and after transcribing the recorded information, a thematic analysis was employed for the emerging theme.

Results

Policy implementers at the central level identified key challenges in the management of NCDs medicines, such as supplier delays, poor data quality from health facilities, and difficulties in handling unexpected donations. At RMS Ltd branches and district pharmacists, challenges included limited storage space for nutrition products, transportation issues, inconsistent availability of products, unforeseen additional costs, and data quality concerns. The healthcare professionals (HCP) addresses these challenges through effective stakeholders communication, available resource management, early planning, selecting reliable suppliers, increasing sponsorship, supervision and capacity building of the staff at health facilities.

Conclusion

The management of NCD drugs and nutrition products in Rwanda's health supply chain faces challenges related to medicine stock-outs, budget constraints, and inadequate inventory data recorded by health facilities, hindering informed decision-making. Policy implementers showcased various approaches to mitigate these challenges. However, investment in the quality of inventory data is crucial, as it can inform a risk-based inventory approach and foster the optimal utilization of available funds.

Health Supply chain

efficiency

NCDs products

Nutrition products

In the past decades, infectious diseases posed the primary health challenge in Low and Middle-Income Countries (LMICs). However, there has been a significant shift, and currently, Non-Communicable Diseases (NCDs) are on the rise in LMICs. NCDs account for approximately 17 million premature deaths annually worldwide, with a staggering 86% of these occurring in LMICs (1). Despite global efforts to combat malnutrition, both acute and chronic malnutrition continue to increase in Sub-Saharan Africa (SSA) (2–4). Unfortunately, the availability of NCD medicines and nutrition products to individual patients remains inadequate in LMICs. This lack of access increases the risk of undermining the effectiveness of healthcare services and hinders progress toward achieving target 3.8 of the Sustainable Development Goals (SDGs), which is related to attaining Universal Health Coverage (UHC) (3, 5, 6).

Limited financing remains a significant challenge in ensuring the availability of medicines and commodities to combat NCDs and address nutritional needs, despite the establishment of mechanisms under SDGs goal 2 and 3.4 aimed at securing stable funding for these objectives (13, 14)(7). The capability of Sub-Saharan Africa (SSA) to handle the escalating burden of NCDs and provide adequate nutritional support is hampered by fragile health systems, insufficient infrastructure, and limited resources. This situation has led to a continuous reliance on Non-Government Organizations (NGOs) within the countries and regions to address these pressing healthcare issues. In most LMICs, the Ministries of Health have developed NCDs prevention policies along with comprehensive packages intended to address the burden of NCDs. Despite these efforts, there have been continuous reports of inadequate implementation (8–12).

The use of parallel supply chains for managing health products reduces the efficiency of supply system. This approach reduces the effectiveness of accessibility to medicines because different programs operate independently, leading to duplication of efforts and maintaining separate supply chains. For successful supply chain integration, it is crucial to combine all relevant activities and potential strategies within a harmonized framework. The integration should focus on ensuring efficient and effective processes, following best practices, and ultimately satisfying the customers' needs (13–15).

In Rwanda, efforts to improve the efficiency of the health product supply chain have led to the establishment of Rwanda Medical Supply Ltd (RMS Ltd) under the Ministry of Health. This integration has notably enhanced the availability and accessibility of medicines for treating communicable diseases. However, when it comes to NCDs, several challenges hinder the effectiveness of the supply chain. These include poor management practices, inadequate data, limited training, high staff turnover, insufficient capacity, and the bulk supply of donations without effective collaboration beforehand. Consequently, these factors contribute to the limited availability of NCDs medicines (16–21). Most previous studies conducted in Rwanda have primarily used the quantitative approach to identify gaps in managing nutritional products and NCDs medicines. To gain a more comprehensive understanding of the challenges and possible solutions for maintaining an uninterrupted supply of NCDs medicines and nutritional products, it was essential to gather the insights and perceptions of professionals working in health supply chain management. This study was conducted to explore perspectives of policy implementers on enhancing supply chain management for NCDs medicines and nutrition products in Rwanda.

Research design

This study was a descriptive cross-sectional study designed using a qualitative approach. Interviews were carried out with healthcare professionals working in the supply chain of NCDs medicines and nutrition products management to gain insights into the efficiency of health supply chain in Rwanda. These interviews were conducted over one month period in March 2023.

Study setting

The study was conducted at both central and peripheral levels that involves in the management of the health supply chain in Rwanda. At the central level, participants were recruited from Rwanda Biomedical Centre division of Non-Communicable Diseases (RBC/NCDs) and division of Maternal Child and Community Health (RBC/MCCH). The participants from Rwanda Medical Supply ltd (RMS Ltd) headquarter in the quantification unit that are responsible for planning and stock management were included. The RBC implements policies set by the Ministry of Health (MoH). Through the RBC/NCDs and RBC/MCCH divisions, the institution ensures the availability and accessibility of NCDS and nutrition products respectively. RMS Ltd headquarter office manages and distributes health products to all government health facilities throughout the country, by operating through its branches.

At the peripheral level, participants were recruited from RMS Ltd branches and the pharmacies of provincial and district hospitals. RMS Ltd branches receive health products from the headquarter and redistribute them to various health facilities including hospitals and health centers. These hospitals and health centers are service delivery points providing NCDs and nutrition products, as well as other health products to the clients. Therefore, the availability and affordability of NCDs medicines and nutritional products at health centers significantly contribute to fighting NCDs, and acute and chronic malnutrition.

Sampling technique and study population

Study participants were selected using purposive sampling based on their role in the health products supply chain management. The study recruited a total of 51 participants. At Central Level, the study recruited two staff members from RBC/NCDs, two staff members from RBC/MCCH divisions, and five staff members from RMS Ltd Headquarter. At the peripheral level, the study included 32 staff members from RMS Ltd Branches, and ten store managers or pharmacists from hospitals.

Data collection

A semi-structured interview guide was developed to collect data for this study. The questionnaires were designed to gather information about the management of the supply chain, with the aim to understand the current state, identifying the challenges, and exploring the mechanisms to mitigate these challenges. To direct attention to the commonly consumed products, participants were asked about specific products during interviews. For NCDs products, the participants were asked about blood glucose test strips, blood pressure machines, insulin, and warfarin tablets. Regarding nutrition products, the participants were asked about Corn Soya Blended (CSB) and Fortified Blended Food (FBF) commonly referred to as Shisha Kibondo commonly used in management of malnutrition in Rwanda.

The interview guide was validated through a pilot study involving four individuals from the study population, and it was found suitable to be used in the current study. The interviews were carried out in person at the respondents’ workplace. Study participants were informed that the interview will be audio-recorded, and they provided signed informed consent before starting. Each interview lasted for an average of 30 minutes.

Data analysis

Thematic analysis was used for data analysis. The audio recordings were repeatedly listened to become familiar with the words of participants, and were used to write transcripts. Each audio recording was given specific participant number, and later used to name transcripts. An independent reviewer checked transcripts for accuracy. Three researchers participated in the coding process to ensure trustworthiness and validity. Among data coders, one researcher (IN) worked at the central level of health supply chain management in Rwanda for more than 13 years. Data coders read transcripts thoroughly and get familiarized with data, developed initial codes from the statement of participants, and generated themes. Data were analyzed manually, and themes were developed from transcripts. The results were checked for validity with study participants.

Characteristics of study participants

The study participants were 51 professionals working in the health supply chain management levels. At the central level, we recruited four policy makers at RBC that oversees nutrition, diabetes and hypertension products, and five policy implementers at RMS ltd headquarter. At the peripheral level, we recruited 32 professionals working at RMS ltd branches, and ten pharmacists of district hospitals. The themes were categorized into three main categories: Challenges at the central level, Challenges at the peripheral level, and mechanisms of mitigating challenges.

Challenges at the central level

Policy implementers that participate in management of NCDs and nutrition at the RBC and RMS headquarter highlighted the six themes about the challenges in health supply chain management: delay of suppliers, poor quality of data from health facilities, irrational distribution of products across RMS Ltd branches, managing unexpected donations, reliance on funders, and lack of long-term planning. Normally, funders help RBC to get health products including CSB and FBF by sponsoring purchase, but the amount of money they provide varies. There is no long-term planning of the budget that will be used to purchase products. In case of shortage of funders, the government uses an ordinary budget to purchase the products, but it is limited due to the high demand. There is a continued effort to engage as many funders as possible to secure future needs of the nutrition commodities. “Funding mechanism is not sustainable; we rely on donor’s money. That's why we go by what they gave us at the time, but in the years to come we won't know what will happen” (Participant 3).

In NCDs division, some products are sponsored while the others are not. Policy makers in NCDs division actively develop partnerships that help to raise sufficient budgets, but sponsors often align donations with their own objectives. The products that are found on the list of essential medicines are likely to get funders. Division takes the responsibilities of buying products that are not found on the list of essential medicines with an ordinary budget despite the rising pressure of their needs. The highlighted example is glycated hemoglobin, which is bought merely with sponsorship. Some funders also provide products with conditions that limit equitable access among the target population of NCDs division. For instance, NCDs division receives donation of insulin and glucose test strips with conditions of distribution to the people below 25 years old, and the division is expected to use products on medical need basis, with no selection based on social factors. This causes the NCDs division to buy the same products to be distributed in uncovered groups of people. “...they are the ones who give us insulin for free, but for children under 25 years of age, and we are responsible for discussing with the partner who gives it to us to align the donation with insulin that RMS buys” (Participant 7).

At RMS headquarter, policy implementers participating in quantification and procurement of NCD products at the central level (RMS ltd) expressed that normally, NCD products are purchased by one government agency (RMS ltd) using its ordinary budget. Most of the policy implementers perceive funding as insufficient due to the unstable budget that depends on purchasing power of health facilities. “NCD products are purchased by RMS ltd from its ordinary budget at the same time health facilities buy these products from their own funds, hence the consumption of these products is affected by buying power of health facilities which leads to inconsistent consumption rates for those products” (Participant 2). Some policy implementers perceive irregular donations as important in improving availability of essential medicines, but a challenge in the management of stock.

Poor stock management practices in RMS ltd branches causes irrational distribution of the products, which can cause imbalance of quantity in stock across blanches. The imbalance is accelerated by the fact that branches determine the quantity they need, and the central level provides all requested quantities if present. “All branches can request whatever quantity of medicines they propose, and the validation of their orders doesn’t consider inventory control parameters of branches as well as the consumption rates in respective branches.” (Participant 9).

Challenges at the peripheral level

The study revealed the challenges in supply chain management practice at RMS Ltd branches and health facility level. Professionals working in RMS Ltd branches and hospital level highlighted five themes regarding health supply chain management: Storage space for nutrition products and their transportation, inconsistent availability of the products, unplanned additional costs on the products, poor quality of data, and persistence stock out of some products. Management of nutrition products requires a large storage area, and improved transportation system. When central level management receives procured nutrition products, they are sent to the RMS Ltd branches, which causes overload of the products. “The products are supplied in big volume and require much space, which is difficult to accommodate in our small storage space with other health products” (Participant 26). This also causes RMS Ltd branches to distribute bulk quantities of the products to the health facilities. Handling larger quantities of the products than usual challenges both RMS ltd branches and health facilities.

Transportation of products from RMS Ltd branches to health facilities is also a big challenge not only in terms of vehicles available, but also poor road infrastructures. “For FBF, the district oversees transport but sometimes, the vehicles are not available on time, and the trucks do not reach every corner because of road’s problems'' (Participant48).

Health facilities experience stock out that results from problems in supply chain management at higher levels. Nutrition products were reported to experience stock out for extended periods of time “Experiencing a persistent and generalized stock out of both products (FBF and CSB). For FBF, the factory is in stock out because of its limited production capacity; however, CSB has been out of stock for a long time and the reasons are not known” (Participant 31).

Mechanisms of mitigating challenges

Five themes were highlighted regarding management of challenges in health supply chain management: increasing communication with stakeholders, managing available resources, early planning, and increasing sponsorship and increasing supervision and training. At the beginning of each fiscal year, the MCCH division communicates with RMS Ltd to find the quantities that shall be procured and align with the current financial status. This facilitates early negotiation of the products and the bulk procurement that reduces the needed budget. They communicate also with health facilities to get prepared for long-term storage of the products. The divisions also increase efforts of finding partners who can sponsor product procurement, and if the budget for needed products is not collected, the Government uses its budget, which might be limited due to the other issues that wait for the Government's expenses. “We work with RMS Ltd to develop a procurement plan so that they can approach the factory early and have a plan. We communicate with the regional hospitals or pharmacies to secure the place where these products should be stored while waiting for their distribution to beneficiaries” (Participant 1).

Most of the products in the NCDs division are bought with RMS ltd. ’s own generated budget, except warfarin, which can get funds. The main challenge raised in the NCD division is the poor quality of data from health facilities. To solve the problem, they increased supervision and training of staff at health facilities. The central level of RMS ltd mitigates the challenges by improving the quality of the supply chain, assessing, and selecting reliable suppliers, and improving communication with stakeholders. “The main mechanism for mitigating this challenge is to improve the regular communication between RMS and RBC/NCD division to find priority in case of understock, risk of stock out, and stock out” (Participant 8).

Supply chain management of health products is coordinated at the central level by RBC in close collaboration with RMS Ltd, under the supervision of Rwanda Ministry of Health. In Rwanda, the supply chain management system is decentralized from the Ministry of Health, RBC, RMS Ltd central level, RMS Ltd branches, hospitals, health centers, health posts, community health workers, and individual clients. Our study found that funders align their supply chain with the national system. This promotes the integration of supply chain management in Rwanda and highlights that the management system can effectively manage donations without causing duplication of efforts or other problems associated with parallel supply chain management. The supply chain management in Rwanda is comparable to the management system used in other African countries like Nigeria, where its Ministry of Health set up a semi-autonomous entity- National Level Medical Store (NLMS), and Zambia that set up Medical Stores Limited (MSL) to purchase, store, and distribute medicines and medical supplies across the whole nation (15).

We found the main challenges to the efficient management of the health supply chain to be unstable funders, limited ordinary budget, unreliable suppliers, poor data quality, stock-outs, limited storage capacity at health facilities, and dependency on imports. These challenges are comparable to the study conducted by Anna Schöpperle on the analysis of challenges of medical supply chains in sub-Saharan Africa regarding inventory management, transport and distribution (22). In previous years, the supply chain management was overseen by the Medical Procurement and Production Division of RBC in Rwanda, which is the top management level reported in previous studies; its main responsibilities were taken over by RMS Ltd in August 2020. Currently, RMS Ltd coordinates procurement and supply chain management of health products in Rwanda (23).

One of the challenges to the whole health supply management system is the poor quality of data generated at the health facility level. In our study, key informants highlighted that the problem is associated with high work overload in hospitals and health centers, which left a limited time to produce quality data. This has been highlighted in previous studies that reported the poor performance of the health system in Rwanda (24). Central-level management of the health supply chain highlighted the need of training to the staff involved in stock management at the health facility level and increasing field visits as one of the mechanisms to mitigate the problem of poor data quality. The similar mechanism has been proposed in a study conducted in Ghana, which recommended a systemic assessment of supply chain and stock management practices as a way of improving quality (25).

Our study reported the lack of enough local production capacity for nutrition products as a challenge to the efficiency of supply chain management. Dependence on imports exaggerates delays of suppliers, and increased risks of stockout. This is in line with a recent study conducted in Rwanda on local manufacturing of generics products, which reported the limited manufacturing capacity as one of the challenges to the availability of health products (26). Different studies conducted in Sub-Saharan Africa reported limited local production capacity of nutrition products to cause long lead time of manufacturers and suppliers (22, 27–29).

Our study explored the efficiency of supply chain management in Rwanda with an emphasis on NCDs and nutrition products. The supply chain management for nutrition and NCDs products is effective despite the hurdles that need to be addressed. Policy makers can improve management by refining the strategies including early planning, improved communication throughout the supply chain, and financial resource mobilization. Increasing infrastructures and capacity building for the health professionals working at health facility level will solve the problems associated with storage space and quality of data generated at the facility level. In Rwanda, health services have been decentralized from central to the community level, and community health workers are playing a significant role in providing health products to people. Future research is needed to explore management of the health supply chain at health centers, health posts, and community level.

Limitations of the study

The study did not assess the efficiency of health supply chain management at the health centers, health posts, and community health workers levels while they play a major role in data generation and consumption of the products.

Funding

This study received no funding.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

The study obtained ethical clearance from the National Health Research Committee (Reference number: NHRC/2022/PROT047), and Institutional Review Board of College of Medicine and Health Sciences at the University of Rwanda (Reference number: 024/CMHS IRB/2023). All participants signed informed consent before participating in the study. All study procedures were performed in accordance with the 1964 Declaration of Helsinki.

Consent for publication

N/A

Availability of data and materials

Dataset used in this study are not used publicly available due to the risks of identifying participants, but will be made available on reasonable requests to the corresponding author.

Authors contribution

IN and JN participated in study design, data collection, data analysis, data interpretation, and drafting of manuscript. EN participated in study design, data analysis, data interpretation, and drafting of the manuscript. OS participated in data analysis, data interpretation, and drafting of the manuscript.

Acknowledgements

We are grateful for the contribution of Jurdas Sezirahiga in the development of study design.

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Version 1

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You are reading this latest preprint version

Enhancing the health supply chain for non-communicable diseases management in Rwanda: A qualitative exploration of the perceptions from policy implementers.

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Version 1

Abstract

Background

Methodology

Results

Conclusion

Background

METHODOLOGY

Research design

Study setting

Sampling technique and study population

Data collection

Data analysis

RESULTS

Characteristics of study participants

Challenges at the central level

Challenges at the peripheral level

Mechanisms of mitigating challenges

Discussions

Conclusion

Limitations of the study

Declarations

References

Status:

Version 1