Local Supply Chains for Medicines and Medicinal Supplies in Kenya: Understanding the Challenges

This Working Paper presents some findings from a research project on Industrial Productivity and Health Sector Performance, collaborative research by the African Centre for Technology Studies (ACTS), Nairobi; REPOA, Dar es Salaam; and The Open University, UK. The project aimed to identify opportunities for improved local industrial supply of medical products to strengthen Kenyan and Tanzanian health system performance. This working paper briefly outlines project methods and key concepts. It then summarises findings from health sector research in four Kenyan districts on the supply chains for selected essential medicines and supplies to facilities in the public, private and faith-based sectors and to private shops. The paper analyses strengths and weaknesses of the public and private supply chains into the health sector, as seen by health facility and pharmacy staff

Improving the Supply Chains for the Health Sector: What Role for Locally Manufactured and Imported Medicines and Medical Supplies in Kenya?

This Issue Paper presents some findings on research on supply within Kenya from local manufacturers to the health system. It compares the sourcing of local supplies and competing imports within the public, private and faith-based sectors of health care. Finally, it presents perceptions of Kenyan health sector actors at all levels on the extent to which improved local manufacturing supplies could help to increase access to essential medicines and medical supplies within Kenya. The evidence presented here was collected as part of a research project entitled Industrial Productivity and Health Sector Performance (www.iphsp.acts-net.org).This was a collaborative research project undertaken by the African Centre for Technology Studies (ACTS), Nairobi; REPOA, Dar es Salaam; and The Open University, UK. The project aims to identify opportunities for improved local industrial supply of medical products to strengthen Kenyan and Tanzanian health system performance

The Social Pain of Cancer in East Africa: Understanding Need

Cancer is both an individual physical, social and psychological crisis for a patient with one of the many forms of this category of non-communicable disease, and also a cause of deep social pain. Cancer spreads its tentacles through families and friends, social groups and the wider economy, generating stigma, financial destruction, social and psychological damage. This chapter makes the case for a very broad social understanding of cancer need, framing cancer as a whole-society problem, with psychological, social, economic and spiritual impacts much wider than the sufferer. This framing also implies greater attention to survivability and human dignity in policies, practices and provision

The Cancer Care Challenge in the Light of Pandemic Experience

This introductory chapter argues that tackling the escalating cancer crisis in Africa and India is essential for human wellbeing and inclusive health care, while having much to teach about how to build better local health security in low- and middle-income contexts. Global health security is built on the foundations of strong local health security. Local health security in turn relies on effective and innovative industrial supply chains to provide essential medicines, devices and other commodities at manageable prices, and effective industrial-health sector policy collaboration to ensure broad health benefit, lessons the pandemic has hammered home

Access to Cancer Care: navigating the maze

This chapter analyses narratives from over 450 patients in Kenya and Tanzania, describing their cancer “pathways”, drawing also on views from carers and health workers. We characterise patients’ experiences as, too often, finding themselves in a “maze” after they first visit a health facility. Rather than a smooth clinical pathway from symptoms to diagnosis, patients had found themselves struggling to find money to move through a confusing health system maze, largely without maps or guides to aid their search for information, diagnosis and treatment. The chapter describes patterns of experience within the maze, and implications for access to care

Conclusion: Better Cancer Care and Greater Local Health Security: Lessons, Opportunities and Ways Forward

In pulling together the book’s analytical themes and practical lessons in the conclusion, this chapter emphasises as a core theme the scope for bringing together health, industrial development and innovation to build greater local health security, for cancer care, across the spectrum of health need and pandemic preparedness. The pandemic and our study of cancer care reinforced the importance of simultaneous co-resolution of challenges pertaining to health systems strengthening, development of broad industrial capabilities and improvements in planning, organisational, funding and institutional capabilities. This is critical for building agile and resilient local health security, a critical pre-condition for global health security

Rethinking health sector procurement as developmental linkages in East Africa

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012–15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa

Health-industry linkages for local health: reframing policies for African health system strengthening

The benefits of local production of pharmaceuticals in Africa for local access to medicines and to effective treatment remain contested. There is scepticism among health systems experts internationally that production of pharmaceuticals in sub-Saharan Africa (SSA) can provide competitive prices, quality and reliability of supply. Meanwhile low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. We present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. We then identify key policies that can ensure that local health systems benefit from the investments. We argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. We argue that this local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions

HIV testing services in Kenya, Tanzania and Zambia: Determinants, experiences and responsiveness

Introduction: HIV/AIDS has been one of the most challenging pandemics in health and development. Sub- Saharan Africa remains the most affected region and it handles over two-thirds of the individuals infected world wide. A large number of interventions have been implemented to control the infection. HIV testing is one of these interventions, and is a key entry point for both prevention and treatment. HIV testing has mainly been offered through the client initiated, voluntary counselling and testing (VCT) services. However, low use of VCT has been reported in several studies despite substantial scale-up during the past 10-15 years. Provider-initiated testing and counselling (PITC) models have been introduced to increase the test rates in the context of the growing availability of treatment. Nevertheless, little has been documented on experiences with the PITC model. This study sought to assess exposure to HIV testing through VCT and the prevention of mother to child transmission (PMTCT) based testing services that practice PITC at antenatal clinics, investigate determinants of VCT use, explore experiences and perceptions with the PITC model within PMTCT program and assess the applicability of the responsiveness concept in the evaluation of VCT. Methods: The thesis comprises of: 1) a cross-sectional study of 5689 respondents in three African districts; 2) a concurrent triangulation mixed-methods study that utilised data from: a population-based survey in three study districts, 34 focus group discussions and 18 in-depth interviews; and 3) a concurrent nested mixed-methods study applied in one of the study districts among 328 VCT users and 36 VCT counsellors. Results: The findings indicate that education attainment and stigma were significantly associated with VCT use across the three districts. Women were much more likely to test for HIV than men in the two districts with seemingly higher use of PMTCT. Only minor gender differences appeared for VCT use. PMTCT-based HIV testing was not always accompanied by pre-test counselling and limited post-test counselling was experienced. In settings where the PITC model had been scaled up extensively through the PMTCT program, informants expressed frustration related to their experienced inability to ‘opt-out’ or decline from the providerinitiated HIV testing services. There was an experienced additional burden on women testing through the PMTCT program as they were encouraged to recruit their spouses to go for HIV testing. The elements proposed by WHO to measure responsiveness were highly valued in a VCT context. However, qualitative findings revealed pertinent aspects of the elements (e.g. confidentiality and autonomy) that were experienced as crucial in the local setting, but had not been captured by the tool. Conclusion: Variations in HIV testing exposure was largely related to the extent to which the PITC model had been scaled up through the PMTCT program in the three districts. Determinants of VCT use differed less by district. Education attainment and HIV stigma were dominant factors related to HIV testing across the three districts. This underscores the need to improve efforts to promote education and effective anti-stigma programs to reduce inequalities in HIV testing. Variation in exposure to overall HIV testing in the study populations can mainly be explained by the extent to which the PITC model had been scaled up through the PMTCT programme. However, scaling up of HIV testing at PMTCT settings seem to reach mainly pregnant women. Whereas this strategy seems beneficial in increasing the test levels, the manner in which the PITC strategy is currently implemented raises serious ethical concerns; the removal of the pre-test component of counselling leaves no room for obtaining informed consent; and the approach implies missed preventive opportunities that are inherent in the post-test counselling concept. Responsiveness provides a fruitful concept to evaluate HIV testing services; however, the WHO responsiveness tool needs substantial revision in order to capture elements of experiences relevance for the local context in which it is employed