LUSAKA, April 21, 2010--There is less malaria in Zambia today than there was only a few years ago, thanks to large-scale efforts such as distributing insecticide-treated bed nets. But even with these major advances in prevention, the disease remains endemic and is still a leading cause of death in the country, especially of children.
Recognizing that access to proper treatment needed to be stepped up, the World Bank, the UK’s Department for International Development, and USAID joined forces to try out new drug distribution methods in 16 districts in Zambia. The results from this pilot are exceptionally encouraging.
Simple but smart steps to grease the supply chain for lifesaving drugs—including hiring district-level planners to help manage orders and deliver more efficiently—have proved very effective. Pediatric malaria drugs, so essential to save children’s lives, have become available in 88 percent of public health centers in the pilot districts. This is nearly double the 51 percent availability rate in the control districts.
If the pilot is scaled up and supply chains are strengthened nationwide, an estimated 27,000 children could be saved from malaria-related deaths in Zambia by 2015. This could potentially reduce the country’s child mortality from malaria by 37 percent, effectively complementing prevention efforts.
“Countless more lives, both of children and adults, could be saved because the same supply chain operates for other drugs and supplies as well, including antibiotics and condoms,” said Monique Vledder, the Senior Health Specialist who oversaw the project at the World Bank.
Why supply chains matter
The Zambia National Malaria Indicator Survey (2008) reported that just seven percent of children in rural areas under the age of five received pediatric ACT (Artemisinin-Based Combination Therapy)—the most effective first-line medicine for malaria—within 24 hours of starting a fever.
This statistic translates into tragic losses in villages across Zambia. While children often fall victim to treatable diseases for lack of drugs in public health centers, boxes of critical medicines can gather dust for weeks at district storage facilities. Frequently, nobody at the district level knows of shortages in the villages so drug shipments languish where they are least useful, on the shelves of a storage facility.
The pilot was set up in 2009 to address such breakdowns in the drug supply chain. Its impact was measured a year later, by the World Bank working with John Snow Inc. and Crown Agents, in collaboration with the Massachusetts Institute of Technology (MIT) and the MIT-Zaragoza Logistics Program.
“The difference between life and death can be painfully simple in rural areas,” said Vledder, “Our work has focused on identifying the best way to get drugs to the right place at the right time, maximizing the effectiveness of every public health dollar spent in the process, and delivering tangible results.”
Removing deathtraps at the district level
“In the past, we used to get a lot of prescriptions without access to actual medication,” said Mwansa Kasonde from Kasama in northern Zambia. “They would tell us to go and buy from drug stores whose price was exorbitant. These days, we are able to get free medication then and there from our nearest health facility.”
In the districts where the supply chain improvements were introduced, pediatric malaria drugs are now available 345 days out of 365, with an average downtime of only 20 days a year compared to 247 in control districts. Stories with happy endings are no longer the exception here.
The pilot project tested two different distribution models, finding both to have beneficial results. Both methods involved hiring an all-important commodity planner at the district level, who took care of placing and seeing through orders for supplies for public health centers at the village level.
“Drug availability has improved tremendously, particularly anti-malaria and antibiotics. Drugs are now supplied in bulk. We have the ability to do physical count and order according to demand,” said Oscar Bwalya, who works at the pharmacy in the Mungwi Rural Health Center, 30 kilometers from Kasama. “This has ensured access to a variety of medicines by our community.”
The more dramatically successful of the two methods simply docked drug shipments at district storage facilities, without needing to unpack or repackage shipments. Orders for village health centers were made well in advance based on actual needs assessed by the planner, using previous consumption data.
“This pilot has shown that some of the most entrenched obstacles to drug supply chains in Zambia can be solved through better system design,” said Prashant Yadav, an expert on supply chain management at MIT’s international logistics program in Zaragoza. “I am impressed by the project’s results because supply chain problems in public health systems are notoriously difficult to fix. This project has created new knowledge on how to improve drug supply chain design in low income countries.”
Scaling up based on proven impact
Jed Friedman, senior economist with the World Bank’s Development Research Group, is upbeat about these results, which he helped to evaluate.
“These results are exceptionally positive, especially since this particular study did not involve a large number of districts – we tracked pharmaceutical information in eight randomly chosen control districts to compare with our 16 pilot districts,” he said, “At the Bank, we are building state-of-the-art impact evaluation components into an increasingly large number of projects.”
The importance of aid effectiveness has been driven home yet again by the financial crisis. More than ever, aid funds need to be spent in as efficient a manner possible. Experiments such as this one, which have demonstrable results, help to ensure that development projects have maximum impact and efficiency.
If the new method were scaled up across Zambia, it would imply that an additional 110,000 children per year can receive the right treatment for malaria on time in rural public health centers. This translates into an estimated 27,000 lives saved by 2015—essential progress as Africa continues to work towards the Millennium Development Goals, among which reduced child mortality is a key target.
But the impact of supply chain improvements is not limited to malaria drugs for children.
The pilot study also found that with the improvements, malaria preventives for pregnant women became available in 84 percent of public health centers in the pilot districts (compared to 39 percent in control districts; and amoxicillin, an important antibiotic, was available 91 percent of the time in pilot districts (compared to 70 percent in the control districts).
Even as the Zambian government seeks to scale up this pilot across the country this year, the potential for supply chain improvements across Africa is very apparent.
“I hope that our findings will help strengthen the public sector’s ability to provide life-saving drugs to the population—not only in Zambia, but also in other places,” said Vledder. “Simple, well-designed improvements put in place by multiple partners working together effectively could really make a difference across many parts of Africa.”