Description
The logistics systems for all health commodities present a tangled picture, with overlapping systems and information, as well as public sector and private sector players. This report focuses on family planning commodities logistics, while recording other systems and identifying their existing and potential relationships with contraceptive provision systems.
Uganda Logistics Systems for Public
Health Commodities: An Assessment
Report
May 1 – 21, 2000
Final Report
Prepared by:
Sangeeta Raja, Steve Wilbur and Bonita Blackburn
John Snow Inc./Family Planning Logistics Management (FPLM)
United States International Development Agency/Washington
Contributors:
Ministry of Health/Uganda
United States International Development Agency/Uganda
Delivery of Improved Services for Health Project II
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FPLM
The Family Planning Logistics Management (FPLM) project is funded by the Office of Population of the
Bureau of Global Programs of the U.S. Agency for International Development (USAID). The agency’s
Contraceptive and Logistics Management Division increases the awareness, acceptability, and use of
family planning methods, and expands and strengthens the managerial and technical skills of family
planning and health personnel.
Implemented by John Snow, Inc. (contract no. CCP-C-00-95-00028-04), the FPLM project works to ensure
the continuous supply of high quality health and family planning products in developing countries. FPLM
also provides technical management and analysis of two USAID databases, the contraceptive procurement
and shipping database (NEWVERN), and the Population, Health, and Nutrition Projects Database (PPD).
This document does not necessarily represent the views or opinions of USAID. It may be reproduced if
credit is given to FPLM.
Recommended Citation
Raja, Sangeeta, Steve Wilbur and Bonita Blackburn Uganda Logistics System for Public Health
Commodities: An Assessment Report. 2000. Published for the U.S. Agency for International Development
(USAID) by the FPLM project. Arlington, Va.
FPLM
Family Planning Logistics Management
John Snow, Inc.
1616 North Fort Myer Drive, 11
th
Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
E-mail: [email protected]
Internet: www.fplm.jsi.com
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Acknowledgements
The Family Planning Logistics Management project (FPLM) of John Snow, Inc. wishes to
acknowledge the contributions of the following organizations who provided time, staff and data
to assist in completing the assessment:
ORGANIZATIONS
• ACP
• CARE
• CMS
• DANIDA
• DFID
• DISH II
• FPAU
• Iganga District
• HSSP
• JMS
• Kamuli District
• Mbale District
• MOF
• MOH - Health Services
• MOH - Reproductive Health
• MOH - Resource Planning
• MSI
• NDA
• NMS
• Pallisa District
• Population Secretariat
• RTC
• STIP
• Survey Department
• UNEPI
• UNFPA
• USAID
• World Bank
A special thank you goes to the U.S. Agency for International Development (USAID)/Uganda,
the Ministry of Health and the Delivery of Improved Services for Health (DISH) II project, who
provided valuable input and support in completing the assessment.
We are particularly grateful to the U.S. Agency for International Development (USAID)/REDSO
Mission for funding the assessment.
Finally, we would like to thank everyone we have met during the assessment and who are too
numerous to mention. All of them have given their time and information freely, and their
dedication to providing the best possible service to the people of Uganda has guided and
encouraged the suggestions in this report.
As always, the recommendations in this document are those of the consultants, but are based on
the collective experiences of the FPLM project and on the wisdom and ideas of those working on
a day to day basis within Uganda. We hope (trust) that these recommendations will be helpful in
improving logistics system and are prepared to work with all parties to implement the suggested
improvements.
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Table of Contents
Acknowledgements ....................................................................................................................................... 3
Acronyms....................................................................................................................................................... 7
Executive Summary...................................................................................................................................... 9
Key findings ............................................................................................................................................... 9
National Level........................................................................................................................................ 9
District and Health Facility Level ........................................................................................................ 10
Recommendations .................................................................................................................................... 11
National Level...................................................................................................................................... 11
District and Health Unit Level ............................................................................................................. 13
Situation....................................................................................................................................................... 15
Objectives: ................................................................................................................................................... 16
Methodology................................................................................................................................................ 16
Background ................................................................................................................................................. 17
Ministry of Health Organization and Structure ........................................................................................ 17
Sector Wide Approach ............................................................................................................................. 18
Public Health Supply Chain Systems ....................................................................................................... 18
Logistics Systems for the Management of Public Health Supplies .......................................................... 21
Essential drugs ..................................................................................................................................... 21
Contraceptives...................................................................................................................................... 21
Uganda National Expanded Project on Immunization (UNEPI).......................................................... 22
Integration Possibilities........................................................................................................................ 22
Product Selection ........................................................................................................................................ 23
Procurement ................................................................................................................................................ 26
Forecasting ............................................................................................................................................... 26
Donor Coordination.................................................................................................................................. 28
Drug Regulation and Importation............................................................................................................. 28
Product Review with NDA....................................................................................................................... 29
Distribution.................................................................................................................................................. 31
Warehousing............................................................................................................................................. 31
National Medical Stores....................................................................................................................... 31
Ordering.................................................................................................................................................... 33
Ordering and Delivery processes from the National Medical Stores ................................................... 33
Ten Percent Handling Charge .............................................................................................................. 35
Inventory Control at the NMS.................................................................................................................. 37
Expired Products handling at the NMS level............................................................................................ 38
Joint Medical Stores ................................................................................................................................. 38
Transportation............................................................................................................................................ 38
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Logistics Management Information System............................................................................................. 39
Forms Used in the System........................................................................................................................ 39
Impact of MOH Changes to HMIS Forms................................................................................................ 41
Social Marketing for Contraceptive Products.......................................................................................... 42
Commercial Market Strategies (CMS) ..................................................................................................... 43
CMS Condoms..................................................................................................................................... 43
Oral Contraceptives.............................................................................................................................. 44
Injectaplan............................................................................................................................................ 44
Other Products...................................................................................................................................... 45
Summary.............................................................................................................................................. 45
Recommendations: ............................................................................................................................... 45
Marie Stoppes International - MSI Uganda............................................................................................. 46
Private Sector Contraceptive Products ..................................................................................................... 47
Family Planning Association of Uganda ................................................................................................... 47
Recommendations....................................................................................................................................... 48
The Reproductive Health Unit of the Ministry of Health......................................................................... 48
USAID and Other Donor Organizations................................................................................................... 52
DISH Project ............................................................................................................................................ 53
Other Stakeholders ................................................................................................................................... 53
Bibliography................................................................................................................................................ 54
Appendix 1: Scope of Work..................................................................................................................... 57
Appendix 2: The Logistics Cycle ............................................................................................................. 63
Appendix 3: Schedule............................................................................................................................... 64
Appendix 4: People Contacted ................................................................................................................. 67
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Acronyms
ACP AIDS Control Programme
CBD Community Based Distribution
CMS Commercial Marketing Strategies
CYP Couple Year Protection
DANIDA Danish International Development Assistance
DDHS District Director for Health Services
DHMT District Health Management Team
DHV District Health Visitor
DfID Department for International Development
DISH Delivery of Improved Services for Health
FPAU Family Planning Association of Uganda
GoU Government of Uganda
HMIS Health Management Information System
HSSP Health Sector Strategic Plan
IPPF International Planned Parenthood Federation
JMS Joint Medical Stores
KfW Kreditanstalt fur Wiederaufbau
KPI Kampala Pharmaceutical Industries Ltd.
MOF Ministry of Finance
MOH Ministry of Health
MSI Marie Stopes International
NDA National Drug Authority
NMS National Medical Stores
RLI Regional Logistics Initiative
STIP Sexually Transmitted Infections Project
SWAP Sector Wide Approach
UDHS Uganda Demographic and Health Survey
Ugsh Ugandan Shillings
UEDSP Uganda Essential Drugs Support Programme
UNEPI Ugandan National Expanded Programme for Immunization
UNFPA United Nations Population Fund
USAID United States Agency for International Development
WB World Bank
WHO World Health Organization
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Executive Summary
The logistics systems for all health commodities present a tangled picture, with overlapping
systems and information, as well as public sector and private sector players. This report focuses
on family planning commodities logistics, while recording other systems and identifying their
existing and potential relationships with contraceptive provision systems. There are national level
issues to be addressed, and district and other health facility levels issues that require
improvement. This report uses the components of the logistics cycle to track systems and make
recommendations based on national and district level needs.
These findings and recommendations were presented and discussed during a stakeholders
meeting with a large number of key players in Uganda at the conclusion of the consultancy. They
are presented here in bullet form as a brief summary of information presented in more detail in
the rest of the report. The recommendations are presented in more detail at the end of the report,
organized by agency for easier tracking.
Key findings
National Level
General
• Public health commodities reach the customer through several separate logistics systems.
These include MOH, CMS, MSI, JMS, FPAU, UNEPI and the private sector.
• Some aspects of the logistics system in the MOH are integrated while others are managed
separately. Systematic integration of the supply chains could result in cost and time-savings
and improve product availability and efficiency at the service delivery level.
Product Selection
• Essential drugs are selected from the essential drug list and the standard treatment guidelines.
• The donors and the RH unit select a wide range of short and long term contraceptive methods
based on family planning policy guidelines.
Procurement
• Importation regulation according to the NDA statute resolved.
Forecasting
• Capacity of the RH unit extended and manpower not sufficient.
• Many data sources available for projection – but none are complete.
• Consumption not known at the national level.
• New changes proposed in the new HMIS forms will make forecasting even more difficult.
• Donor coordination meetings taking place – need to extend its role to include review of all
logistics issues.
Warehousing
• NMS has the capability to manage the distribution and warehousing to pharmaceuticals.
• 100% match of the physical count with the computerized inventory at NMS.
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• 10% handling fee at the NMS contorts the delivery system – resulting in delay in delivering
district supplies from 3 weeks to 3 months.
• Inventory control computerized and managed at the NMS.
• Responsible programme in MOH notified 6 months prior to the expiration of any product.
Transportation
• Drugs being delivered to all 45 districts every quarter based on a set schedule.
• Deliveries occur within 1 week of the scheduled date.
LMIS
• Service statistics reported by the districts to the central level.
• Data used to revise the kits
• HMIS database managed at the central level. Data includes aggregated service statistic
reported by the districts.
District and Health Facility Level
Procurement
• Small amounts of drugs bought from local suppliers using user-charge fees.
• Perceive quality of drugs to be better and more reliable from the NMS.
Forecasting
• No forecasting currently done at the district level.
Warehousing/Storage
• No basic shelving in most of the stores in the districts visited – difficult for the storekeeper to
organize and distribute products.
• Storekeepers not trained in basic storekeeping procedures.
Inventory control
• Contraceptive stock cards not kept up to date.
• Lack of inventory control and management.
• Lack of ordering skills to base orders on max and min.
• Lack of skill to calculate months of stock available.
• Too many progesterone-only pills in the facilities visited. Large stock of VFT at all levels.
• Stocks not ordered until total stockout.
• When the stocks are ordered, various methodologies are used to determine the order quantity,
(consumption, service statistics, guess work).
• Most facilities visited had at least 2 – 3 contraceptives that were stocked out at the time of the
visit.
• Procedure manual not available.
Transportation
• Essential drugs and vaccines delivered to the clinics.
• Local initiative by staff from both the clinic and the district level manage to arrange the
transport to deliver/collect the supplies.
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LMIS
• Essential data (stock on hand, dispensed/issued, adjustments/losses) collected at different
places by different people, but not synthesized and not used for decision-making.
• Reports sent to HQ incomplete or delayed (3-6 months).
• Districts have initiated report tracking. This has improved the reporting timeliness.
Use
• Reported increase in the use of Depo Provera
• Low consumption of PoP, IUD, and VFTs.
• User fees for family planning services applied differently at each health facility.
Human Capacity
• Most of the staff do not have training in logistics.
• Roles and responsibilities of each staff involved in the management of the logistics system
not clarified or documented.
Recommendations
National Level
A. The Reproductive Health Division with external technical assistance should do CPT
commodity forecasting in July 2000 for the year 2001 and beyond. It should use all possible
data sources including demographic projections, DISH district survey data, 200 site dispensed
to user data and HMIS data to produce short and long term projections.
B. Contraceptive Security – provision of adequate supplies – needs to be closely tracked,
especially as donors shift to sector wide approach programs. Continuity of supplies must be
insured during this transition period and adequate contraceptive supplies included in the
SWAP budgeting. Reproductive Health Division and donors, supported by logistics technical
assistance, must be responsible for the inclusion of supplies planning. At the present time,
with ordered supplies included, there is at least a 2-year supply for most contraceptive
products. Now is the time to plan for beyond two years, using 2001 CPT projections.
C. The Contraceptive Coordinating Committee should have a formal meeting every 4 months,
coordinated by the RH Division. The meeting would review stock-on-hand data, shipment
coordination, issued and dispensed to user data, problems that arise, information and product
status that need to be shared. This meeting should include all donors and potential donors, all
social marketing distributors, all providers of family planning services, the NDA, National
Medical stores and MOH sections such as Reproductive Health, Planning unit resource centre
and ACP.
D. Donor procurement should involve the National Drug Authority in procurement planning,
especially with new commodities, new manufacturers or even new labeling, to avoid
clearance delays and possible exclusion of products.
E. All contraceptive commodity importers must ensure that not only is the product registered
with the NDA, but that packaging and labeling must meet NDA specifications. Any changes
in packaging or labeling requires notification to the NDA.
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F. USAID/Washington should note in the Newvern system that any changes in product,
manufacturers or packaging must be notified to the NDA.
G. USAID/ Washington should consider adding the Date of Manufacture to each condom
primary packet, at the time of the next worldwide production contract. This would comply
with WHO specification guidelines and conform to other condom labeling.
H. FPLM and USAID/Washington should send to NDA all agreed upon documentation and
FPLM should provide a USAID-supplied products documentation and sample folder.
I. USAID/Washington should review shipping and payment instructions with Panalpina and
with Kampala Pharmaceutical Industries.
J. Technical assistance in logistics planning and advocacy should be provided to the
Reproductive Health Division from specialized external expertise and with on-going local
logistics support, primarily from the DISH II project. This combination would strengthen the
capacity of the RH to coordinate forecasting, procurement and district level improvement.
K. If for any reason, USAID procured condoms are requested for Uganda for the public sector,
the RH Division must obtain in advance a waiver from the NDA for the importation of these
condoms.
L. The ten percent handling fee on the value of commodities due the NMS for handling, storing
and shipping supplies to the district level is such an obstacle to a smooth and efficient
ordering process that it should be made a guaranteed payment and taken out of the ordering
approval process. Options to do this range from 1) RH securing guaranteed funding 2) donors
prepay this 10% when commodities are received by the NMS, 3) a guaranteed amount be
authorized by line item in the sector-wide planning budgets or 4) a guaranteed amount be
included in the health sector debt-relief budgets.
M. If provided with a clear delivery order from the MOH and payment for services, the NMS has
the facilities, transportation and human resources to deliver contraceptive and other medical
supplies to the District level in a timely and efficient manner.
N. Dispensed to user data from a previously conducted 200 site survey should be entered and
analyzed. This work could be coordinated by the DISH II project and be used in calculating
the 2001 CPT report.
O. FPLM to provide technical assistance for contraceptive procurement in procedures,
specifications and quality control.
P. USAID/Uganda should consider sending RH Division and other key officials for Arlington
logistics training ASAP to build a cadre of trained officials.
Q. FPLM should encourage and arrange Uganda participation in RLI regional logistics activities.
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District and Health Unit Level
A. Expired stock and damaged materials should be collected and removed from health facilities
and district level storage areas.
B. Basic storage job aides should be developed, disseminated and personnel trained.
C. Procedures manual need to be developed for district and other level inventory control and
stock ordering. The process should include the following:
design workshop to achieve agreement on procedures and forms,
development of training manuals and on-the job training aids,
testing of training in DISH and other project areas,
inclusion of logistics training in other training packages,
training of both policy decision makers and operational cadre,
emphasis on issued to user data for decision making.
D. Use resources of DISH Project and other projects to advocate for, test and support
implementation of inventory and ordering capacity building.
E. Use Supply Chain Manager computer system for inventory control and ordering in DISH
projects as a pilot for eventual nationwide use.
F. Define role of sub-district health center in logistics activities. The consultant’s initial
recommendation would be to avoid stock storage at this level.
G. Include drug, vaccine, contraceptive and other medical supply ordering in any district level
guidelines, tools and training.
H. Consider integration of contraceptive and other commodities with quarterly distribution of
essential drug kits to reduce costs and improve delivery.
I. Design and institute a system to re-distribute commodities in oversupply.
J. Look for funds to install basic shelving in the district stores.
K. Train storekeepers in basic storekeeping management, including documented storehouse
procedures.
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Situation
Uganda, a land-locked country in East Africa, has achieved marked economic growth for the last
five years due to sound macro economic policies, liberalization and privatization of the economy.
However, household incomes have remained low, resulting in poor health indicators (MoH/HSSP,
1999).
The population of Uganda is estimated at 21 million with a total fertility rate (TFR) of 6.9.
Compared to regional neighbors, Uganda suffers from a heavy burden of disease. 75% of life-
years lost to premature death are due to ten preventable diseases. 20.4% of these deaths are a
result of perinatal and maternal related condition (MOH/HSSP, 1999). Use of family planning is
low in the country, with only 7.8% of the married women using modern contraception, while
91.6% of the women reported knowing about contraception (UDHS, 1995). In addition, Uganda
also has the highest adolescent pregnancy rates in sub-Saharan Africa (DISH Evaluation Survey,
1997).
Continued availability of contraceptives is essential to contraceptive use. In the last two years,
repeated stockouts of contraceptives were registered at national, district and facility level.
Monitoring of the Couple Year Protection (CYP) provided by the public sector institutions has
shown a marked decrease during 1999, when condoms went out of stock all over the country for
more than six months and the injectable contraceptive showed similar trend at the end of the year.
Several logistics factors have been identified as the cause of countrywide stockouts. These
include:
• delays in-country procurement clearances due to tighter implementation of the importation
rules by the National Drug Authority (NDA);
• outstanding debt owned to National Medical Stores (NMS);
• donor dependent supply system which resulted in changes in product availability,
• restrictions on procurement and financial cuts faced by donors;
• decentralization of health services resulting in lack of information available at the central
level to plan for nationwide procurement.
United States Agency for International Development (USAID)-Uganda and the Ministry of
Health (MOH) recognized that availability of contraceptives was not only essential for achieving
program objectives, but also crucial for saving women’s lives from unwanted pregnancies. To
ensure adequate and timely supplies of contraceptives, the Mission and the MOH requested John
Snow Inc./Family Planning Logistics Management (FPLM/JSI) to conduct an assessment of the
reproductive health logistics system and provide operational recommendations.
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Objectives:
The main objectives of the assessment were:
1. To assess the status and function of the logistics-based activities of key partners at all levels
of the Uganda supply chain for reproductive health supplies.
2. To identify main causes of recurrent stockouts of contraceptive supplies and identify areas
that need to be strengthened or streamlined in order to improve the flow of the products
through the system.
For the complete scope of work and other objectives of the consultancy covered (see appendix 1).
Methodology
The assessment was conducted as a joint collaboration between the Ministry of Health (MOH),
USAID/W, USAID-Uganda, Delivery of Improved Services Health (DISH) II and JSI/FPLM.
USAID/REDSO and USAID/Africa Bureau through the Regional Logistics Initiative provided
the financial support.
The assessment was based on a systems approach, using the logistics cycle as framework (see
appendix 2) to ensure a complete and systematic review of all logistics-based activities, at all
levels of the supply chain, from central level to the health facility. All public health product flows
currently existing to get the commodities to the customer were assessed.
The team used key informant interviews and review of the records at each level of the system to
gather the data. A final interview and observation schedule appears in (see appendix 3). Cross-
checking of the data reported by the different levels was done with the level above or below and
with as many people as possible.
The first week, the team interviewed stakeholders in Kampala. In the second week, a team of
USAID-Uganda staff, Ms. Betty Nabirumbi, DISH Logistics Officer, Mr. Muyingo Sowedi, two
FPLM staff, Mr. Steve Wilbur, Country Team Leader and Ms. Sangeeta Raja, Logistics Advisor
visited four districts in the eastern part of Uganda. The team, in consultation with USAID, MOH
and DISH, choose a purposive sample to visit. The eastern part of the country was chosen
because it was possible to cover more districts supported by a range of donors, was logistically
feasible in the time available to conduct the assessment and represented similar conditions to
other districts.
Reproductive health staff at the national MOH level were not able to join the team during the
field visit due to a heavy workload. However, Dr, Florence, Ebanyat, Assistant Commissioner,
RH Division provided a letter of introduction that the team could give to the DDHS of each of the
district. One of the members of the district health team (DHT) accompanied the team when
visiting the health facility within that district.
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Table 1: Sites visited to assess the supply chain at the district and health facility level.
District Site visited
Donor Supporting the
District
Kamuli Kamuli District Office
Level III Clinic
USAID
Pallisa Pallisa District Health Office
Buseta Clinic
DfID/ UNFPA
Mbale
Mbale District Health Office
Budadiri Sub-District Clinic
Buwalasi Clinic
UNFPA Regional RH Program
Coordinator
DfiD
Iganga Iganga District Health Office
Muyuge Health Center
UNFPA
Kampala Kiswa Health Centre UNFPA, USAID
Quantitative indicators such as stockout rates, percentage stocked according plan, wastage rates
were not collected as part of this assessment since the DISH Project will be conducting a
quantitative survey to assess the drug supply situation at the health facility level in June and July
2000. FPLM consultants provided written suggestions to their survey.
This report by the consultants describes, in depth, the structure of the system, mode of operation,
relationship between the different divisions and levels and provides recommendations for
improving the logistics system.
Background
Ministry of Health Organization and Structure
Uganda administratively is organized into 45 districts, which is further divided into counties, sub-
counties, parishes, and villages. At each level, there is a local council, made up of politically
elected and administrative staff in charge of the area. In order to bring quality health services
closer to the community. Health Sub-districts are being created to cover a county. Any hospital,
(GOV or NGO) or a health centre within the county will be upgraded to Health Centre IV, will be
the referral unit for the HSD. The HSD will provide technical support and supervise all health
units within county. It will also be responsible for community outreach services.
At the central level, the Ministry of Health has several technical units including the RH Division
that provides guidance and policy support to the 45 districts.
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Sector Wide Approach
To reduce the mortality and morbidity from the major causes of ill health, the MoH, other key
ministries and its development partners have developed a Health Sector Strategic Plan (HSSP).
The health sector reforms include decentralization to the 45 districts and sub-district level,
outlining a basic minimum package of health services to be delivered to the Ugandan population
through the districts and formulating policies, standards and guidelines for the delivery of health
services.
In support to the sector wide approach, some donors, mainly, Department for International
Development (DfID), Swedish International Development Agency (SIDA), Irish Aid and the
World Bank are preparing to support a common basket funding.
A major concern for family planning activities is the donor funds earmarked for purchase of
family planning commodities will now be placed in the basket funding, with uncertain results for
commodity purchasing. This must be tracked closely by the RH Division and the donors to ensure
that sufficient products will be available under the new approach.
The sector wide approach will start from July 1, 2000. As of this date, PHC conditional grants
are being allocated to the districts to implement the priority programs they have developed under
the MOH guidelines. However, there are also district based donor funded activities that provide
extra support to certain areas. The SWAP approach is designed to permit more equitable
distribution of resources, but both systems will co-exist for some time.
In view of the high maternal and child mortality rates, reduction of fertility through family
planning has been identified one of the objectives of the HSSP. However, there still a poor of
understanding at the national and sub-national level of the impact of population growth on
development and health. Many of the stakeholders interviewed felt that family planning received
a low priority by the key decision-makers.
Health Supply Chain Systems
Ugandans can access health commodities through various channels. These include buying from
private vendors of all types, MOH health facilities, social marketing programs and NGO operated
facilities.
Health supplies are brought into the countries by donors, church organizations, government of
Uganda and private companies. They usually arrive through two ports of entry, Mombassa for sea
freight and Entebbe for airfreight. Most suppliers use freight forwarders to assist in the clearance
of customs.
Prior to being allowed in the country, the supplies are inspected by the National Drug Authority
(NDA) and given a seal of approval for entry. Depending on the circumstance and the quantity,
the NDA can take one day to a month to inspect a consignment. The commodities are then stored
in the various warehouses before they are distributed through the different channels.
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Lead times to get supplies into the country are dependent on the supplier’s procurement systems,
but can range from 2 months to 3 years. Unlike some countries, there is no procurement unit
within the MOH supply chain to coordinate the planning and procurement of supplies.
It has been shown in the private sector logistics that aligning the strategies of the various
suppliers within the supply chain has decreased the total cost, increases customer fulfillment rates
and increases the overall profitability of all the suppliers in the supply chain. In the case of the
Uganda, the strategies of all the suppliers (e.g. donors, NMS, districts, clinics) involved in the
public sector supply system, are not harmonized. This makes it difficult to create a smooth
logistics system that can result in a win-win situation for all the stakeholders.
There is therefore need for all the stakeholders in the supply chain to develop a harmonized
strategy that would ensure a win-win situation for all. Different individual objectives sometimes
work against common goals. The public health supply chain would benefit if all stakeholders
reviewed their objectives together and developed a harmonized strategy with shared performance
indicators. These indicators could include monitoring of total delivered cost, customer
satisfaction index etc.
Table 2: Impact on Supply Chain when Strategies are not harmonized
Supply chain
stakeholders
Strategies/Issues impacting
supply decisions
Result to supply chain
Donors
• Purchase the best product at
the lowest cost
• Funding available only through
a certain period
• Restrictions on procurement
• Bulk purchases, mean large
shipments which clog storage space
• Long-term planning not possible
• Overlapping products
NMS
• Provide services at a low cost
(break even)
• Pressure to Increase charges
• Decapitalization
• Reduce service
• Delay orders
District
• Ensure supplies are there
when customers needs them
• Local purchasing
• Increased transportation costs –
seek ways to get supplies released
from NMS
Health Facility
• Ensure supplies are there
when the customer needs
them
• Local purchasing
• Referring customers to other supply
chain (social marketing)
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Figure 1: Supply chain for Public Health Commodities
Kfw
Italy
WB
USAID
DfiD
UNFPA
KfW
IPPF
DANIDA
GoU
Churches
IDA/WB UNICEF
Rotary Int’l
GoU
UNAIDS
UNICEF
TB FP ED STI Vaccines
Vitamin A
Anti Viral
Drugs
Port of Entry
Mombassa Entebbe
Freight Forwarders
NDA
FPAU MSI KPI/CSM NMS
(Entebbe)
NMS
(Kampala)
JMS RH
Office
UNEPI
Private Vendors
DISTRICTS
HEALTH FACILITIES
GoU and NGO
CUSTOMERS
Private Vendors
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Logistics Systems for the Management of Public Health
Supplies
Essential drugs
Managed as a push system. The government of Uganda and DANIDA purchase essential drug
kits from the international market. In addition, the government purchases other required drugs
both locally and internationally in bulk. Once in country, the NMS packs them into kits and labels
them for each clinic. The amount per kit is determined periodically using morbidity and
demographic data. The kits are distributed quarterly to the districts, which in turn ensures that
they are directly delivered to the clinics as soon as they are received. Patient load and stockout
data is reported on a monthly basis to the central level. The NMS uses this data to review the
order quantities for each of the kits and make adjustments accordingly. The current max is set at 5
months and min at 2 months for both the districts and the clinics.
Contraceptives
Managed as a pull system. The health facilities order contraceptives monthly from the district
health office based on the last months’ consumption. The districts order their supplies every
quarter from the NMS. Due to management issues discussed in detail in the report, this system is
currently not fully operational. The health facilities reports dispensed to user data every month to
the district. The district in turn aggregates the data of all the clinics and reports to the planning
unit at MOH where the data is entered into a database. Like the essential drugs, the current max is
set at 5 month and min at 2 months both at the district and clinics. The national level max is at 12
and the min at 9 months.
Figure 2: The contraceptive logistics system
DONORS
DfID, UNFPA, USAID, WB, KFW
NMS
Districts (45)
Health Facilities (+1156)
CLIENTS
Planning
Unit
RH Unit
Key
Product Flow
Information
Flow
ACP
22
Uganda National Expanded Project on Immunization (UNEPI)
Logistically, UNEPI maintains a separate vertical procurement, storage and distribution system
from the national level, down to delivery at the SDP. Vaccine distribution requires maintenance
of a continuous cold-chain, which drives this extensive logistics system. The vaccines Tetanus
Toxoid are BCG, DPT, Polio, Measles and Tetanus. UNEPI also distributes Vitamin A capsules,
which were originally distributed as part of the National Immunization Day (NIDS.)
UNEPI maintains a well-equipped warehouse for vaccine storage on the grounds of the National
Medical Stores, but it operates independently. It has a fleet of three ten-ton trucks, which carry
only UNEPI supplies. There are four large refrigerated storage units, with temperature controls
and back-up generators, plus other storage space at the warehouses.
Forecasting is essentially done on a demographic basis, with targets to reach 80% of the children
in Uganda in the year 2000. Procurement is done through UNICEF, and supplies arrive regularly
on a quarterly basis. Because this has been an on-going coordination for many years, lead-time is
very short, documentation is routine and there are no problems with NDA or customs clearance.
Procurements are air freighted in, cleared from the airport to the UNEPI that day and put directly
into cold storage.
There is monthly delivery to each District, according to a delivery schedule. UNEPI does not
deliver to four districts for security reasons, so supplies are delivered to nearby districts and the
affected districts must pick up their commodities. All districts are in radio contact with the central
warehouse. Each district has a cold chain manager, who is the focal point for tracking
commodities. Propane cylinders for refrigerated units are delivered on a 2-bin, replacement
system and refrigerated units for repair are transported back by UNEPI trucks.
From the districts to the SDPs, supplies are both delivered and picked up. Most districts have a
motorcycle with a cold box for regular delivery to the health facilities. One-month supply is
supposed to be kept at the HU level. The district makes distribution decisions, theoretically based
on user data. Wastage is locally recorded and locally disposed.
Vaccine coverage has declined in recent years, but this is not related to logistic issues.
The consultant discussed with the UNEPI staff the question of logistics integration. With their
facilities within the NMS compound, separate trucks going to the same District Centers and
parallel staffing, this is an obvious question. There was recognition of the pressure to integrate
systems and a sense that this will eventually happen, but an understanding that this would be
some time in the medium to far future. With the special requirements for cold-chain maintenance,
strong donor financial support and the uncertainties of other logistics systems, it is not likely that
this vertical system will be dismantled anytime soon.
Integration Possibilities
As mentioned above, there are several parallel logistics systems operating. These include
Essential Drug Kits; STI kits and drugs TB/Leprosy drugs, family planning commodities and
vaccines.
The key to this possible integration is the Essential Drug kit delivery system, which distributes
these kits every three months on a regular schedule. Since the ED kit system is unlikely to be
23
changed anytime soon, other delivery systems can piggyback on this system. With STI drug
procurement moving from separate project status to inclusion in the Sector Wide Approach
system, procurement and a coordinated delivery will likely be absorbed into the NMS system. TB
and Leprosy drugs are now delivered by NMS to TB regional centers, which then distribute them
to district centers. This system does not need to be maintained separately and can certainly be
integrated at the NMS, with delivery directly to the districts.
The original objective for family planning commodities was that they be distributed with the
essential drug kits. With shortages requiring the districts to scramble for supplies, MOH inability
to pay for the NMS 10% distribution fees to the NMS throwing distribution off schedule and
inefficient ordering from the District level, this possible system has fallen apart. If the 10%
handling fee issue can be resolved, it will be possible to organize district ordering to fit with a
three monthly delivery schedule for essential drug kits. Since the farthest point for delivery to the
Districts is only 9 hours, emergency delivery off schedule is also practical. Individual donors will
still do procurement, but storage once received in country, and delivery from the Center to the
Districts, can be accomplished by the NMS system.
Vaccines is not likely be integrated anytime soon due to special handling requirements.
Tanzania has demonstrated an effective integration of essential drugs, vaccines and
contraceptives. The Medical Stores Department does some procurement, receives all supplies and
delivers them to the district centers. They maintain the cold chain for vaccines to the district level.
This system seems to be working effectively. Family planning supplies were the last to be
integrated. FPLM assisted in this integration, a process that took almost two years.
The MSD in Tanzania is sufficiently efficient that socially marketed contraceptives are stored by
them and distributed to provincial (Regional) warehouses, where social marketing staff collects
them for distribution to wholesale and retail outlets. MSD are paid for this service.
Further down the delivery chain, more supplies and systems are effectively integrated. Storage
areas are shared, the staff controlling distribution is the same, and facilities at the SDP level are
often one cupboard containing all medicines and supplies.
Product Selection
Essential drugs are selected from the Uganda essential drug list and those recommended in the
standard treatment guidelines. The program only purchases generic over brand in order to get a
better price for the drugs.
As outlined in the RH policy, a wide range of contraceptives, both long and short-term methods
are currently available through the public and private sector. The method mix includes
injectables, oral contraceptives, and barrier methods.
There seems to be a dramatic increase in the use of Depo Provera and a decrease in the use of
IUD and VFTs. Majority of the condoms are in the system are for the prevention of STI and HIV.
The STI project and AIDS Control Programme (ACP) logistically manage the condoms.
24
Contraceptives are usually selected through a joint process between the RH unit and donor.
However, it has been difficult for the RH unit to keep the balance of ensuring a wide range of
supplies of the same type of brands partly because of the donor restrictions of what products they
can supply. As a result, the system has many brands. UNFPA has flexibility to procure various
types of brands of contraceptives, while USAID is limited to purchase only American-
manufactured brands.
In many of the cases, the brands are of the same active chemical composition. This can be
positive in that women can substitute brand of the same active chemical composition in case the
brand of choice is not available. On the negative side, brands of the same chemical composition
do not increase women’s choice, can create confusion for the clients and are very difficult to
manage logistically.
The team found that Family Planning Association of Uganda (FPAU) had the most number of
brands in their system, followed by the MOH.
The result of a wide range of contraceptive brands in the system has been a result of donor
dependency to provide the contraceptives and inability to secure long term donor commitment for
the provision of contraceptives.
25
Table 3: Methods, brands available at the MOH, social marketing program and FPAU
Method Mix Contraceptive Brand Supplier Recipient Code
No Logo USAID FPAU
Protector USAID CMS
Protector CMS FPAU
Engabu IDA/WB MOH
LifeGuard KfW MSI
LifeGuard MSI FPAU
Condom
Depo Provera DfiD MOH d’’’1
USAID CSM, FPAU d’’’1
Progesterone
Injectables
Norplant USAID MOH h’’’’1 Implants
Copper T 380 USAID
DfiD
MOH, FPAU
MOH
IUD
Lo Femenal USAID MOH h4
Lo Femenal MOH FPAU h4
Duofem (Pillplan) USAID CSM h4
Duofem (Pillplan) CSM FPAU h4
Microgynon UNFPA MOH h4
Microgynon MOH FPAU h4
Eugynon MOH h3
Neogynon IPPF FPAU h1
Combined
Pills
Ovrette USAID MOH h’’1
Ovrette MOH FPAU h’’1
Microval UNFPA MOH h’’2
Microval MOH FPAU h’’2
Progesterone
-only Pills
Conceptrol Foaming Tablet USAID MOH
Conceptrol Foaming Tablet MOH FPAU
Delfoam IPPF FPAU
Cotexmax Jelly IPPF FPAU
Neo-Sampoon UNFPA MOH
VFT
Barrier Diaphragm IPPF FPAU
Note: IPPF stopped providing Noristerat as it was not registered in the country.
Note: The code is taken from the Directory of Hormonal Contraceptives, 1996. Each brand of
contraceptives is given a code, which indicates its composition or formula. For example a women
using microgynon could equally use Lo-Femenal, since both products have the same amount of
active estrogen and progesterone.
26
Procurement
Essential drug kits are procured by DANIDA and provided to the government of Uganda. In
addition, the government also purchases some drugs through international tender procurement. As
there is no procurement unit within the Ministry of Health, the procurement is managed by the
NMS. Tendering systems are in place. Under the sector-wide approach there are several scenarios
being discussed for the management of procurement. These include establishing a procurement
unit, placing a procurement officer under each technical unit and or keeping the status quo.
UNICEF and government of Uganda purchase vaccines. These vaccines are procured through the
UNIPAC catalogue.
The donors procure contraceptives. Since each donor has a different procurement cycle, projected
forecasts are needed at different times of the year. Forecasts for the coming year are usually done
between July – December. The specific donor does procurement, shipping and clearing, with
delivery to the NMS or social marketing systems directly.
Forecasting
Projections for essential drugs are done using morbidity and demographic data. Vaccines are
projected using demographic data and contraceptives are projected using demographic data,
issues data from the national level and surveys that are available at the time. USAID/Uganda has
provided technical assistance through a consultant to determine the forecasts.
Due to lack of data, it is very difficult to know the current stock in the country at the different
levels or consumption rates. This makes accurate forecasting difficult.
27
Table 4 : Contraceptive Stock Situation based at the NMS as of May 16, 2000
MAX: 12 MoS MIN: 9 MoS
Months of Stock Available at the National Level
Contraceptives Based on 1999 CPT
Data
Based on Spectrum
Data
Based on NMS Issues
Data
MOS MOS MOS
Condom 43 55
FP
HIV/STI
Pill 9
Lo-Femenal 17 17
Microgynon 59 378
Microval 20 12
Ovrette 35 29
Implants
Norplant 33 83
Injectable
Depo Provera 16 13 224
VFT 11
Conceptrol 25 24
IUD 6 5
Table 5: Consumption Projections by Different Sources
CPT Projections for 1999 Contraceptives
MOH SM Total
Based on
Spectrum Data
Condom 25,000,000 20,400,000 45,400,000 19,651,045
FP 2,000,000 5,489,662
HIV/STI 23,000,000 14,161,383
Pill 1,625,000 3,291,618
Lo-Femenal 325,000 830,000
Microgynon 325,000
Microval 25,000
Ovrette 120,000
Implants 6,000 6,000 2,398
Norplant
Injectable 700,000 175,000 875,000 836,276
Depo Provera
VFT 200,000 220,000 440,000 436,624
Conceptrol
IUD 8,000 8,000 9,306
SM = Social Marketing
MOH = Ministry of Health
28
Donor Coordination
A series of donor meetings are held to seek donor commitment for the purchase of the projected
quantities for contraceptives for the upcoming years. This process is one of the strengths of the
system. It ensures that donors at least meet once a year and provide commitment to the purchase
of contraceptives and meeting the contraceptive requirement gap. The main donors that support
the procurement of contraceptives are USAID, DfID, KfW and UNFPA. USAID and KfW mainly
provide contraceptives to the social-marketing programs, while UNFPA and DfID provide to the
MOH.
There is close collaboration among the donors and the RH unit, which has allowed them to make
adjustments in product supply as quickly as possible. In the last year, UNFPA had a cut in
funding and was not able to meet its procurement obligations of pills. DfID managed to bring
emergency shipments, which averted a national stockout.
Drug Regulation and Importation
The National Drug Authority (NDA) was established in 1993 by the act of parliament. The main
mandate of the organization is to ensure that drugs brought into the country are of a good quality.
The NDA has regulatory authority over all drugs and medical supplies in Uganda, including all
contraceptive products. Their approval is necessary for the importation of all contraceptive
products. They follow World Health Organization (WHO) guidelines for contraceptive
specifications. All imported products must be registered with the NDA. In addition, all packaging
and labeling must be registered with them. When manufacturing or packing changes are made,
these changes must be registered.
NDA also has the authority to conduct quality control tests on all products. This is done both in
Uganda and externally, depending on need.
In early to mid-1999, several batches of condoms to be imported failed initial quality control
testing. Extensive quality re-testing, and destruction of some condom batches, contributed to a
serious stockout of condoms in the later half of 1999.
In addition, NDA undertook extensive review of all labeling and packaging for all importers of
condoms – the STI Project, CSM and MSI. Detailed compliance with WHO specification
guidelines was required for all parties and some packaging and labeling changes were needed.
These packaging, labeling and quality control issues raised by the NDA seem to have been sorted
out for all parties importing condoms at the moment. This of course must be tracked closely by
the Stakeholders group, since any delay in importation or acceptability of condom requirements
for Uganda will effect all parties and total supplies throughout the country.
In a similar manner, the NDA has closely monitored importation of all other contraceptive
products. Again, all issues seem to have been worked out, but this must be closely monitored.
As part of the program to address and rectify any questions on contraceptive quality and labeling
from US sources, USAID/Uganda asked Ms. Bonita Blackburn, USAID Contraceptive
Procurement Specialist to accompany the FPLM logistics assessment team. The specialist met
with the National Drug Authority to answer any questions about US products
29
Product Review with NDA
On May 3, 2000, the team accompanied by Florence Ebanyat, Assistant Commissioner for
Reproductive Heath, MOH, met with Dr. John Lule, Acting Executive Secretary, Francis Otim,
Drug Assessment and Registration and Gabriel Kaddu, Senior Inspector of Drugs at the National
Drug Authority (NDA). A review of the status of the registration of USAID contraceptives
was the topic of our meeting.
The team gave an overview of the their objectives followed by a brief description of the provision
of USAID contraceptive to the family planning and HIV/AIDS prevention activities in Uganda.
The team reviewed with the NDA each USAID contraceptive product that is imported into
Uganda beginning with the 52mm non-colored Blue/Gold condoms (52NG).
52NG condoms: USAID condoms meet all the WHO standards and all the WHO specifications
with the exception of the labeling. The WHO standards are developed by the International
Organization for Standardization (ISO) and are designed to establish a minimum level of quality
for products (e.g. condoms) that are imported and sold, within a particular country or region. The
WHO specifications are a buyer's requirement and simply sets package integrity requirements for
condoms because they have to withstand tropical or other conditions of storage and distribution.
The WHO specification requires that all condom foil sachets be labeled with both the
manufacture/expiry dates and the lot numbers. USAID condoms only have the expiry date and
the lot numbers on the foil sachets. USAID does not have the manufacture date on the their
condoms. It is not part of the design factor in our contract.
USAID ships condoms to 60 countries worldwide. In l999, USAID shipped approximately
94,500,000 pieces. In order to do meet this volume, USAID has to award large, multi-year
contracts. These multi-year contracts allow manufacturers to schedule continuous production and
pass substantial savings along to the Government. In l998, USAID negotiated a contract with a
U.S. manufacturer, London International Group (LIG), for a period of three years. This contract
outlined the USAID specifications required from the manufacturer in order to provide the
condoms. This contract specifies that the individually packaged condoms (foil sachets) are to be
marked with the manufacturer's logo and/or name, production location, "Made in USA", the date
of expiry and the manufacture's lot number. Bonita continued to explain that no other country
that receives USAID condoms requires both the manufacture and expiry dates on the foil sachet.
The NDA pointed that that it is their responsibility to the people of Uganda to ensure good quality
condoms. Their concerns centered on clients receiving expired product. The team pointed out to
the NDA that the USAID condom is a good quality product and that is what they wanted for
disease prevention activities. There can be exceptions to the labeling but no exception to the
performance or manufacturing requirements of the condom. USAID condoms meet both ISO and
ASTM standards. In addition, USAID condoms are tested by an independent laboratory, Family
Health International (FHI), and USAID can provide quality assurance documents for each
shipment by lot number. In addition to testing, USAID asks FHI to retain samples of each lot for
future testing if there is a quality assurance problem within country.
The Commercial Markets Strategies Project (CMS) in conjunction with PSI and Kampala
Pharmaceutical Industries (KPI), overpacks and distributes USAID 52NG condoms as "Protector"
condoms. These condoms are sold for a small cost recovery fee in private sector clinics
30
countrywide. The local overpacking done by KPI includes all the information required by the
NDA for the importation and distribution of the USAID condoms. In addition, USAID's
inner cartons of 100 condoms also includes all the information (manufacturer/expiry dates, lot
numbers, manufacturer's address, etc) that is required by NDA.
After much discussion, the NDA was willing to agree to the importation of USAID condoms for
the CSM program since the local packaging did include all the information required by the NDA
in accordance with the WHO guidelines.
Since the USAID condoms for the public sector program (52mm non-colored, no-logo condoms)
will not be overpacked with the required NDA labeling, any request by the MOH for USAID-
supplied condoms will require a waiver from the NDA for this specific product.
It is important at this time to point out two significant questions asked by the NDA:
(l) Does the U.S. domestic market use the same manufacturer for condoms? The team
explains that LIG does manufacture condoms for sale in the U.S. domestic market. In
addition, we explained that LIG is a worldwide manufacturer of condoms and that their
Durex brand of condom is a gold star condom, known worldwide.
(2) What is the relationship of CMS with USAID? We explained that CMS is a centrally-
funded project that is funded by USAID to increase contraceptive supply through private
sector partners and commercials strategies. CMS also covers underserved, rural and
urban areas and populations and works to improve governments' ability to rationalize
resources and collaborate with the commercial sector. We pointed out that USAID
determines the specifications for the condoms used in the CMS social marketing
program.
Duofem - The NDA issue with the low-dose oral contraceptive pill, Dufoem, was that it was
registered as Lo-Femenal not Duofem. Although Lo-Femenal and Duofem are the same chemical
formulation, NDA requires separate registrations. The distinction in the names of these products
identifies them either as public sector product or a CMS product. Lo-Femenal is the
public sector product while Duofem is the CMS product. Bonita agreed to provide the NDA with
a Certificate of Free Sale and a registration dossier for Duofem.
Again, NDA was willing to accept this product based on the fact that it would be overpacked as
PilPlan and that it would meet all the WHO specifications.
At this time, we agreed that either USAID or CMS would notify NDA immediately if any
changes in product or packaging occurred in the future.
Depo-Provera: No problems. Registration approved and on file. Product can be imported.
Norplant: Same as Depo. Registration approved and on file.
Summary: All parties agreed that the importation of USAID contraceptives for the CMS and
MOH public sector programs is acceptable to the NDA, with the exception of no-logo condoms
for public sector distribution, which would require a specific waiver.
31
Distribution
The table below identifies the various organizations involved in the distribution activities in the
various programs
Program Distribution Activities
Procurement Warehousing Transportation
Public Sector NMS/Donors NMS/district stores NMS/Recipient
CMS USAID KPI Agents
MSI KfW KPI Agents
JMS JMS JMS Recipient
FPAU FPAU Stores Recipient
Warehousing
National Medical Stores
History, role and responsibilities
The National Medical Stores was created by an Act of Parliament in 1993 and replaced the
Central Medical Stores. The purpose was established as the procurement, storage and distribution
of drugs, contraceptive products and medical supplies. It is a parastatal organization designed to
serve both commercial and public sector service components.
There is extensive documentation, which describes the history, accomplishments and problems of
the NMS, which were reviewed and are referenced in the annex of this document. Here we will
document those facets that are most pertinent to family planning logistics at the present time.
The NMS presently carries 750 products, through computerized inventory. They have a 9 billion
Ugsh turnover per year. (about 6 million US dollars). They provide limited credit for drugs to the
district level. They distribute Essential Drug kits, both STI drug Kits and STI individual drugs,
TB and leprosy drugs to regional TB centers, and they distribute family planning commodities.
They do not distribute or are not involved in the UNEPI vaccine distribution program, though that
program is physically within the NMS compound in Entebbe.
NMS has no role in the procurement of contraceptive products. The purchasing, NDA approval
and customs clearance of these donor-supplied products is handled exclusively by each donor and
RH Division.
The NMS role is to receive the supplies, warehouse and store the products safely and to ship the
products to the district level, when told to do so by the MOH. It is very important to understand
that the NMS has a very limited role. They are essentially a storage and delivery company, with
no role in ordering contraceptives, approving district level orders or making stock requirement
decisions. They receive the products once cleared, store them and delivery them when told where
and when.
32
Facilities
The NMS has a large compound in Entebbe. There are four major warehouses, with racked
storage areas and 2 forklifts capable of moving inventory from any spot. The facilities are well
designed and are well maintained. There is separate storage space for inflammable items,
corrosives, narcotics, and refrigerated items. Receiving and shipping bays are clearly demarcated
and there are kit packing areas if needed. Temperature is reasonably well maintained. While
improvements are possible, the facilities are very good and are well maintained.
There are four trucks available, with four detachable wagons to increase carrying space. There are
5 truck routes set up for delivery. FPLM through the Regional Logistics Initiative has worked
with NMS to implement a computerized transport management system (TMS) to improve the
space utilization and scheduling of these existing trucks. The trucks are aging, but sufficient.
NMS has just build a new warehouse, which will effectively contain only an expected shipment
of STI Project supplies. Condoms will take up a majority of the space.
It is the consultants’ opinion that NMS has the physical facilities, the vehicles and the trained
people to effectively provide storage and delivery service to its district level clients if all proper
documentation where completed in a timely manner. This however is often not the case and
circumstances beyond NMS control often preclude efficient delivery of the product to the field.
For Family Planning products, these circumstances beyond NMS control include:
- inefficient procurement leading to product stockouts
- incorrect clearance and registration leading to clearance delays
- delayed ordering from the district level
- delayed processing of instructions to ship from the RH unit of the MOH
- non-payment of the required 10% handling costs or non receipt of the certification
that MOH funds are available for this payment
From field visits, the NMS is perceived as providing a good service on schedule for essential drug
kit delivery to the district level. When asked if they would use the NMS service if they had other
options, the general response was that they would, since the quality of the drugs was perceived to
be high, with lowered risk of being cheated.
With major stockouts in FP products in 1999, and few other options, this question was not asked
of contraceptive products supplied by the NMS.
It was also noted that NMS has recently established a Kampala branch of the NMS for local sales
and supply within the Kampala area. The existence of a price comparison center has seemed to
help stabilize drug prices in the capital area.
Management Issues
There are several management and organizational issues that jeopardize the on-going work of the
National Medical Stores. As noted, these are fully documented elsewhere, but are briefly
mentioned here because of the potential impact on NMS services in the medium and long-term.
33
One is that there has been no Manager for the NMS for several years. The present management
team is in an acting capacity, which limits the ability to make key long-term decisions and does
not allow for guidance and necessary planning.
There currently is, and has been for some time, the idea that the NMS would be privatized. This
has resulted in current employees operating without employment contracts, and uncertainty
resulting in low employee moral.
The NMS is regularly effected by scandals in drug procurement. Two officials were arrested
during this consultancy visit. This of course effects public perception of the role and value of the
NMS.
In addition to drug procurement losses, the NMS is also in debt, rumored to be in the 4 million-
dollar range. Substantial sums are owed by other branches of the government, and are difficult to
collect. This is partially the result of the dual nature of the NMS, which is to be an efficient
business, but also to provide drugs and service to the people of Uganda. This debt leads to an
increasing decapitalization of operating funds.
It is not yet clear how these issues will be resolved. Privatization is being promoted, and has been
decided philosophically but with 51% of the company to remain in Government hands and a
substantial debt, this may not happen soon. Discussions are on going, but the NMS is in Class II
(second priority) for privatization efforts by the government commission.
Ordering
Ordering and Delivery processes from the National Medical
Stores
The process depends on which type of product is being distributed.
Essential Drug kits, are distributed based on a push system with a pre-calculated number of drug
kits labeled for a specific health unit. These are distributed every three months on a set schedule
and are sent to the district health center for re-distribution, as a closed kit. The 10% handling fee
is paid by the Danida Project, which is then reimbursed from government funds for this
counterpart commitment.
STI kits, the situation is a bit more confusing. Most STI drugs are contained in a kit form, and the
number of kits is pre-set. Ordering is not on a set schedule and kits are sent out usually on a
different schedule from the essential drug kits. The 10% handling fee is supposed to be paid now
by the STI Project, but payment has not been made at all. The drug kits however are being
distributed without this fee payment because of the critical nature of the need for these supplies in
the field.
In addition to drug kits, some drugs are ordered, collected and sent as individual pieces. The
ordering is done theoretically based on client use at the district level, but this is not quite clear.
These drugs are distributed at the same time as the STI drug kits.
34
TB and leprosy drugs are distributed on a push system. The TB officer at the district level orders
the supplies. Supplies are shipped by the NMS after proper technical approvals. These drugs are
then shipped to regional TB centers, and then the district level collects them. While this uses
NMS trucks, it is another separate logistics system.
In the field visit, to the districts, Pallisa and Mbale complained that the regional center for the
eastern region is in Kumi. This has added additional cost in terms of transportation and time for
the district to collect their supplies from the regional centers.
Contraceptive products are based on pull system. The ordering is supposedly done by the
calculation of issues to users, but in practice it seems to be a variety of methods using issue data,
consumption figures, replacement plus 30%, etc. This will be addressed in more detail in a
section on district level training needs. Most of the health facilities pick up supplies after they
have stocked out completely.
Once the order is completed from the district level, it is sent to the RH unit at the MOH. They
review and approve it and send it to the NMS. NMS confirms that order can be supplied and
calculates the 10% distribution fee and send to MOH to process an LPO. The LPO is returned
before delivery is made by NMS. In normal circumstances, this process would run smoothly if
the RH unit received funding allocation from the Ministry of Finance (MoF) to cover these
charges. This year, the government did not achieve the expected revenues. As a result, the MoF
has asked each of the ministries to cut their planned activities in order to be within the reduced
allocated budget.
The RH Division has requested the 10% storage and distribution funds but has not received any
allocation from the Finance Department through the MOH for the last two years. Since the NMS
is also trying to maintain a viable business by charging for their delivery services, they require
payment of this 10% handling fee. With the RH Unit having no approved funds to pay NMS for
this handling fee, this leads to periodic crisis. In the last year, the NMS stopped shipment of
contraceptive products to the field due to non-payment. To get partial payment made, the RH
Unit has had to seek approval from the Permanent Secretary to re-allocate funds for the Ministry
of Health to release.
Now, a guarantee that funds will be paid by the MOH is often required before commodities will
be shipped to the districts. This approval for the handling charge on contraceptives is often
delayed because funds are not readily available.
The NMS can then ship the contraceptive order to the district either with the regularly scheduled
essential drug kit shipment or can ship as soon as possible with other shipments going to the
appropriate district.
The other alternative is for the district to go directly to Entebbe to collect contraceptive products.
In a real local-level effort to speed up the process, some districts will come into Kampala and
Entebbe to speed up the contraceptive procurement. Usually this is done in connection with some
other capital city visit, but it demonstrates a genuine effort to provide needed services to the local
clients.
In this process, the districts must go first to the RH for order approval, then try to get the financial
clearance for the 10% handling charge. It is not often possible to do these things on one visit.
Then they must return to pick up the goods at the NMS warehouse in Entebbe
35
The RH unit has pursued several options to solve the problem of delay in product collection due
to the 10% handling fee requirement. This includes looking at the option of renting a warehouse
of storing RH supplies which was found to be too expensive to storing small amounts of supplies
in the offices at the MOH.
With severe stockouts of products last year, we have seen dedication on the part of the district to
try and acquire needed contraceptive supplies, often at the expense of other district priorities.
Ten Percent Handling Charge
As a private business handling medical supply distribution, the NMS is supposed to be recovering
its handling, processing and distribution costs. It has been decided that a 10% handling charge
would be assessed on the total value of the goods stored and delivered. This is to provide for the
operational costs of the NMS.
This is certainly a legitimate cost, and in fact is probably insufficient for the real handling costs.
NMS estimates that their actual handling costs are 22%. FPLM estimates a 10-15% logistics costs
on the total value are needed for commodity delivery to the district level.
For essential drugs, as mentioned above, this 10% is paid by the MOH as counterpart funds for
the DANIDA support to the essential drug kits (plus 50% of the actual cost of the drugs). This
however is paid immediately by DANIDA to the NMS, and funds are then reimbursed from the
government to DANIDA. Drug requirements however have highest priority, and the DANIDA
project has some clout to insure that this amount is indeed contributed.
For STI drugs, the agreement was that the STI Project would pay that 10% handling charge.
However, this has never been paid to the NMS, with large amounts due. Crown Agents estimated
that the NMS is loosing significant funds in supporting this program. The drugs however are still
being delivered by the NMS.
For contraceptive products, the 10% is paid by some donors and not by some other donors. DFID
does pay this amount. UNFPA and USAID had reached agreement with the Government of
Uganda that this 10% handling cost due to the NMS would be the government counterpart funds
for the contraceptive commodities donated.
This is a logical approach in principal. However, in practice, nonpayment of the 10% is causing
extensive delays in product release, occasional non-delivery of products by the NMS and
complicating the ordering and delivery system to the point that products are being wasted and
stockouts reported at the facility level.
With reduced government revenues, competing priorities and bureaucratic inefficiencies, this
money is usually not paid or is in severe arrears. At the moment, NMS has written the RH unit
saying that the MOH presently owes 198 million shillings for logistics handling costs for
distributed MCH supplies (Approximately $130,000 US dollars.) and threatening non-delivery of
contraceptive products unless the debt is at least partially paid. It was estimated that 75% of this
debt is from UNFPA non-contraceptive supplies.
As a business, NMS should certainly expect to be paid for the service they provide. However, the
reality is that the contraceptive supplies are delayed or not delivered due to this debt owed by the
36
MOH to the NMS. For the period Oct - Dec in 1999, the NMS refused to and didn’t deliver any
contraceptive supplies to the districts.
This even lead to the situation where the RH unit didn’t put contraceptive supplies into the NMS
warehouse for fear that they could not get them released later. So they stored them in RH offices
and distributed them directly to districts that had to come to Kampala to collect these supplies.
This is mentioned only to underline the severe contortions to the logistics system that the
government inability to pay the 10% handling charge is causing. It requires a “Certification of
Availability of Funds” be completed by the MOH to be given to the NMS as part of the product
release cycle to the districts. This tells the NMS that the MOH intends to pay.
This piece of paper is carried back and forth between the NMS and the RH unit, and within
several offices of the MOH itself. If there is a question that the MOH cannot pay, then higher
approval is required.
The handling charge issue adds between 3 weeks and 3 months to the time required to process a
district level order.
From a logistics standpoint, the inability of the Government of Uganda to pay this logistics
handling cost to the NMS creates a total distortion of the logistics system. It lengthens the lead
time to acquire products, it means that district level deliveries miss scheduled transportation and
must wait for another cycle and it means that products are not delivered in a timely manner,
leading to wastage of the product. In short, it creates an unworkable situation.
There are several options in dealing with this 10% handling fee, from immediate to medium term
to long term. For the immediate, it will be important to track the approval or lack thereof for the
272 million Uganda Shilling request for this handling fee made from the RH Unit through the
July 2000 to June 2001 MOH budget submission to the Ministry of Finance. The consultants met
with the appropriate officials at the MOF, and approval is dependant both on government funds
available, plus prioritization by the MOH. The donor organizations can also support this request
as part of MOF allocations connected with each donor. This needs to be tracked closely within
the next two months.
Even if funds are completely allocated at the 272 million level, there is an existing debt of 198
million, leaving little for the coming year costs. And it is likely with Uganda budget shortfalls,
that any allocation would be small.
The medium term is to have the donors cover the 10% handling fee for contraceptive products
supplied by them. DFID is already made this provision and is paying the 10% fee. USAID is
prepared to consider the possibility. UNFPA is prepared to review the need for this 10% fee and
will be conducting an operational review this summer, so the timing for a decision is correct.
NMS can track and bill for these costs per individual donor.
For the long term, funds could be included in the SWAP program, or even in the Debt Relief
program, so that the allocations are guaranteed, but within government budgets. Since many of
these systems are presently evolving, this may take some time and effort to get this allocation
included in these other government payment structures.
37
All parties would even benefit from a 10% reduction in contraceptive purchases by each donor, if
that fund could be used for the 10% handling costs. It would save time, wasted product and
improve service.
As a perspective, in Tanzania, USAID and UNFPA split 50-50 the total storage and distribution
costs for all contraceptive products. This agreement was started in July last year, seems to be
working well, and was brokered by FPLM. This 50-50 is certainly more than the 10% handling
costs requested here.
If it is not possible for the various donors to pay this charge to the NMS in advance when the
product is delivered to their warehouses, then another option might be to have SWAP funds
earmarked from the donor basket to cover this 10% handling fee. The end result would be
improved public sector services.
The RH unit of the MOH has already endorsed this idea. They see no advantage to having to
track down signatories for almost every shipment and would like this obligation to be removed. It
would then even be possible to have requests go direct to the NMS and be filled immediately if
they fell within already approved limits for each district. Elimination of this handling cost from
the RH responsibilities would improve the system enormously. In addition it would free up the
RH staff already over-extended to be able to focus to technical issues of reproductive health.
Inventory Control at the NMS
The NMS has installed a very efficient inventory control and warehousing system, which covers
all products. Shipment lots are tracked and stored by random bins, with computerized printouts
for picking supplies for shipment.
They can provide inventory tracking by supply source, meaning that donor-donated supplies can
be tracked separately. An accounting for the status of donor supplies can be provided within a
few minutes.
Using this same system, the NMS can provide up-to-the-day stock status for family planning
supplies at the request of the Reproductive Health Unit. This information would be very useful
for tracking adjustments needed to supply requests. The consultants would recommend that stock
status information at the NMS warehouses would be a subject for review at the proposed
stakeholders meetings every four months.
The consultants conducted a physical inventory count of all contraceptive products except
condoms in storage at the NMS on May 16, 2000. The NMS staff were particularly helpful in
accomplishing this count. We found that the physical count matched the computer generated
stock list with 100% accuracy in all items. We wanted to highlight this fact to demonstrate that, at
least on this day, NMS inventory control records were up to date and completely accurate.
Table 6: Results of a Physical Count of Contraceptives as of May 16, 2000
Contraceptives Physical Count Record Difference
Conceptrol 265,923 265,923 0
LoFemenal 85,600 85,600 0
Microval 41,596 41,596 0
Ovrette 6 6 0
Depo Provera 9000 9000 0
38
Expired Products handling at the NMS level
There are extensive amounts of expired contraceptive and drug supplies in storage at the NMS.
These expired products are carefully separated and stored away from the “active” supplies, but
the volume is increasing.
There seems to be no present way to dispose of these expired products. In addition to the usual
government regulations concerning expired materials and donor specific disposal requirements,
there are extensive environment regulations that combine to effectively prohibit the disposal of
these products. There appears to be no incinerator in country, which can handle the volume
needed, the high temperature requirements and the pollution control regulations. NMS has made
several proposal to construct such an incinerator but to date have not received the funding
necessary.
Until a high volume, environmentally correct incinerator can be built, contraceptive and drug
supplies will continue to collect at the NMS. At some stage, this problem will need to be
addressed.
Joint Medical Stores
The Joint Medical Stores was set up by the Catholic and Protestant church organization of
Uganda in 1979. The main purpose of the Joint Medical Stores is to deliver high quality
medicines at an affordable price. They currently procure essential drugs, medical supplies and
equipment for the 400+ health clinics and hospitals managed by the NGOs. The JMS mainly
procures through the international market, clears the supplies and stores them. Due to fewer
procurement regulations, JMS is able to have supplies delivered in Uganda ready for distribution
within 3 – 4 months. This enables the JMS to hold fewer inventories, decreasing the warehouse
space requirements and capital tied in inventory.
In the past, the JMS provided supplies on credit; however, this resulted in a major debt being
owed to the stores. As a result, the system operates on a cash and carry system. Credit is only
provided to credit-worthy facilities. The stores inventory turnover is over 4.5 million dollars per
year and estimates that it serves 30 - 50% of the overall essential drug market of Uganda. Some
of the NGO health facilities prefer to receive the supplies in kits, partly because it is easier to
manage and are based in remote districts with limited transportation. The JMS facilitates this by
working with the NMS to purchase the kits and ensuring that the kits are provided through the
NMS distribution system.
At this point, the JMS does not carry contraceptives. However, many of the facilities would like
one-stop shopping, whereby they can collect all their supplies from one point. Orders are
accepted by email, fax or hand delivery of the order forms and can be filled within 10 minutes to
two hours depending on the order quantity.
Transportation
The NMS currently has sufficient vehicles to provide for the delivery of all supplies down to the
District level. There are four Ten-ton trucks, with detachable wagons and 3 smaller trucks. This
fleet is aging, but still functional.
39
These vehicles operate on a regular schedule for delivery of Essential drug Kits every three
months, and also an as-needed delivery to the District centers. Effectively this means they visit
every District Center approximately once a month.
FPLM, through the Regional Logistics Initiative (RLI) has worked closely with the NMS to
install a computerized Transport Management System (TMS) which predicts vehicle routes, truck
loading, vehicle maintenance and fuel and repair costs. This system has been in operation for
several years and seems to be working quite effectively. This is an adaptation of a similar system
used in Kenya.
Logistics Management Information System
At the central level, there are various technical units that are responsible for a specific health
program. These include the Reproductive Health unit, Child Health Unit, STI/HIV/AIDS unit and
so on. Each of these units has reporting requirements and data they need to make national
decisions. The Health Management Information System under the planning unit of the MOH has
developed a set of forms that can be used for local level management and forms that is used for
reporting essential data for decision-making to the central level. Since 1996, the health facilities
throughout the country have been using these forms. A HMIS manual that provides information
on how to feel the data is available at the district level and can be obtained from the planning unit
at the MOH.
In some of the countries where FPLM has worked, the experience has been that the HMIS usually
is focused on gathering the epidemiology data and not the management data, especially logistics
data. This fortunately is not the case of Uganda. There are a set of logistics forms that allow one
to record all the essential data items (stock on hand, losses and adjustments and consumption) in
order to manage a logistics system for each level. However, these data are recorded at different
places but are not brought together to make logistics decisions such as determining order
quantities. The HMIS manual provides instruction on how to fill out the various forms and how to
use the data. However, in the field visit, the team found little evidence that the data was being
used at the local level for making logistics decisions.
Dispensed-to-user data is reported to the central level of the planning unit where the data is
entered into the HMIS database. However, as reported by many key informant interviewers and
reviewing the records at each level, the team found that the reports were late, incomplete, or
missing. Some of the districts visited have instilled a system of posting on the bulletin board the
date the report was received from the facility. The district staff reported that this has helped
monitor facilities that have not reported. Reporting compliance has also improved.
Forms Used in the System
Stock Cards are used at all levels of the system for each commodity. At the NMS, they were kept
with each product. However, in many cases they were not updated since the computer system also
keeps this data. In the districts, stock cards were also kept with the supplies or on the
storekeepers’ desk, which was usually in the store where the supplies were kept. However, many
of the stock cards were not kept up to date. A similar situation was also found at the health
40
facility level. In most of the clinics visited, the team found that there was usually not a stock card
kept for contraceptive supplies. While there is no column for losses and adjustment, most of the
storekeepers interviewed were aware that they should record it as a negative balance. None of the
records reviewed had a record entered for losses and adjustment.
Requisition and Issue Voucher are used at very level of the system to order supplies. A multiple
of three copies per order is used. The first copy stays with the facility ordering the supplies, the
other two copies are sent to the supplier. The supplier retains one copy and the third copy is
returned to the recipient with the supplies. The in-charge of the facility is usually the authorizing
signatory on the order. The form also has a column for current balance. However, in most of the
records reviewed, the team found that that column was usually not filled out. If this data were
provided, the central level would have the data on stock on hand and would be better able to
determine the inventory in the country.
Health Unit Monthly Report are used by the clinics and the districts to report to the level above.
The four-page form provides service statistics data. For family planning, the form reports on
service statistics and number of contraceptives dispensed to clients by brand. This data if reported
could be used to determine the country-wide forecasts. This report was found to be too time-
consuming and is currently being redesigned. In the new form, the family planning dispensed to
user data is being replaced by reporting by method.
Daily Registers for various services are used at the clinics level. These usually notebooks
purchased from the local market. The health workers draw in the various columns that they need.
In the case of the contraceptive register, the columns were titled in a different sequence from page
to page. This practice can result in increased errors when health workers are aggregating data at
the end of the month.
Table 7 : Logistics Records and Reports
Level
Recording and
Reporting Form
Information
Staff
responsible
Facility
record kept
Comments
Daily Register
• Rate of consumption
Provider Consulting
room
no preprinted
registers
Stock card
• Stock on hand
• Quantity received
In-charge In-charge
office
usually no
stock cards for
contraceptives
Requisition & Issue
Voucher
• Stock on Hand
• Quantity received
In-charge In-charge
office
stock on hand
usually not
reported
H
e
a
l
t
h
F
a
c
i
l
i
t
y
Health Unit Monthly
Report
• Rate of Consumption
• # of days stocked out
In-charge In-charge
office
Stock card Stock on hand
Requisition & Issue
Voucher
• Stock on Hand
• Quantity received
DDHS
Storekeeper
DDHS office
Storeroom
stock on hand
usually not
reported
Record of stockouts
• # of days stocked out
Storekeeper Storeroom usually not
reported
D
i
s
t
r
i
c
t
Health Unit Monthly
Report
• Rate of consumption
of all the clinics
aggregated
DDHS DDHS office
In line with the decentralization policies, the objective of the HMIS is to strengthen the districts’
ability to use data for decision-making and reduce the amount that is reported to the central level.
However, it would be very difficult for the district level to make logistics decisions based on the
41
current data. This is because not all the essential data items are reported to the district level; and
there is no one person responsible to pull all the data together so that it can be used to make
logistics decisions. However, assigning and training one or two people to be responsible to
compile and manage the logistics data from drugs, vaccines and contraceptives could rectify this
situation.
Impact of MOH Changes to HMIS Forms
In order to reduce work for the health workers, changes are being made to the HMIS forms so
that only essential data is collected. For family planning, the new HMIS form suggestions include
removal of reporting dispensed-to-user data by brand and replacing it reporting it by method. The
consultants believe however, these will not reduce work for the frontline worker, but in fact will
increase it. Health workers manage their daily family planning registers by brand dispensed. It
would be far easier for the health worker to count each column and transfer the number than to
get the health worker to add all the pills and then enter the number by method on the monthly
report form. If data is received by brand, it is very easy to compile data by method. However it is
impossible to determine the amount dispensed by brand if it is reported by method.
If the dispensed to user data is not reported by brand, this would ensure that the data could not be
used for projecting and improving forecasts. In many of the countries FPLM works in, the
country projections have dramatically been improved due to dispensed-to-user data available by
brand.
The following points are suggestions to the proposed changes that are planned for the HMIS.
The Family Planning Register
• In order to minimize reporting errors, it is better to have pre-printed registers.
• If funding for pre-printed register cannot be secured, staff should be trained to ensure that the column
products are same month to month. Two approaches can be used:
- alphabetically
- by the most popular brand.
E.g. insert the name of each FP commodity in the column
Client Information Amount and type of contraceptive dispensed Other
Services
Reason for
Referral
Serial No. Client
No.
Depo Microgynon Lofemenal Ovrette
Summary of Family Planning by Month and Health Unit Monthly Report
• If the form is to be sent every month, there is no need to have column for each month.
• On table two: From Operating Theatre Register, on the implant column. No. of new acceptors can be
used to determine dispensed to user data.
42
• On the table amount contraceptive dispensed, the data would be more useful if it was reported by brand.
In addition, include a few blank rows in case other brands are added.
• We suggest removing the third table in the new form and replacing it with the following
Contraceptives dispensed Dispensed
Depo Provera
Microgynon
Lofemenal
etc.
• Amount dispensed by method can easily be derived from the above reported information.
• The demand for PoP was very low. By reporting it as all pills it is difficult to use the information to
determine quantities required for each product.
• The Health units usually noted the amount they gave to CBD workers in the daily register as dispensed
and it would create more work if they were to try and separate the data at the end of each month in order
to report it. The Health units would have to consider keeping another register that recorded amount
dispensed to CBD program.
Social Marketing for Contraceptive Products
In addition to public sector distribution of free contraceptive products, the Reproductive Health
Unit of the MOH encourages the distribution of FP products through private sector firms. This is
in keeping with the MOH policy to bring contraceptive products to as broad a segment of the
population as possible and make these products as accessible as possible.
These organizations involved in social marketing of FP products conduct extensive marketing and
brand promotion, distribution and sales through wholesale and retail outlets and bring a quality
product to the consumer. In general, these products are highly subsidized, but with the eventual
goal of sustainability.
In Uganda, the two primary organizations in social marketing of FP Products are Commercial
Marketing Strategies (CMS) and Marie Stoppes International (MSI). They will be described
below.
Market share of socially marketed products has grown steadily, with quite dramatic growth seen
in some products. It was frequently reported during field visits that products that people pay for
are perceived by the purchasing client to be of higher quality. MOH officials at the field level
mentioned that they welcomed the socially marketed FP products, since these products
supplemented free supplies at the health units.
43
Commercial Market Strategies (CMS)
Deloitte & Touche manage the CMS Project, with support from Population Services International
(PSI.) CMS took over from the SOMARC Project in early 1998. SOMARC had been marketing
FP products since 1993. Contraceptive products are supplied with USAID support, and are
imported tax-free.
CMS is promoting and selling the following products; condoms, oral contraceptives, and
injectables. They are planning to introduce emergency contraceptives within the year. They also
sell impregnated bednets.
Their procurement calculations are based on sales data and expected gains or losses in sales.
Their products are imported and cleared by Kampala Pharmaceutical Industries (KPI) who
warehouse the products. KPI also overbrands – with permission – the contraceptive products for
sale and distribution within Uganda.
Eight sales agents, on commission, with 2 motorcycle re-supply couriers in Kampala to distribute
products to various sales outlets. Sales cycles are approximately 2-3 weeks, with products picked
up from the KPI warehouses and distributed personally by the sales agents. These agents also
collect any expired or damaged products for destruction. The farthest sales point is only 9 hours
from Kampala, so quick re-supply is possible.
CMS Condoms
The brand name is Protector. Three protector condoms sell for 100 UgSh (approximately 7 cents
for 3.) Sales figures since 1993 are shown in the table below. As can be seen, sales have grown
steadily. Condom supplies were interrupted in the second half of 1999, and the product was
essentially stocked out from August to December 1999. The reason for this (and other group’s
condom stockouts) is discussed in the section concerning the National Drug Authority.
In the first quarter of year 2000, condom sales have reached almost 4 million. This may partially
be a reaction to the total stockouts of the previous quarter, as commercial outlets re-supply. CMS
is projecting total sales of Protector condoms of 7 to 8 million in the year 2000.
These condoms are USAID-supplied condoms, overpackaged with the Protector secondary
packaging, containing the three condoms. The secondary packaging contains the necessary
information required by the NDA, while the individual primary packet is missing the date of
manufacture. It was agreed with the NDA that the information on the secondary packet is
sufficient for NDA requirements.
In mid-1999, CMS faced packaging and labeling issues raised by the NDA. These issues resulted
in delays of condom shipment clearance and stockouts of the CMS protector brand. These issues
are addressed in greater detail in the section on the NDA regulations, but appear to have been
resolved during this consultancy visit.
44
Table 8 : Sales History of Protector
Year Unit Sales
1993 1,812,488
1994 3,846,381
1995 5,980,285
1996 9,812,520
1997 8,962,380
1998 6,417,420
1999 4,076,880
Oral Contraceptives
The product Duofem, supplied by USAID and produced by Wyeth Industries, is overbranded and
sold as PilPlan. There are 21 tablets and 7 ferrous sulfate tablets per package per cycle and 3
cycles per package. One package sells for 250 UgSH (approximately 17 US cents.) They are
marketed through pharmacies, clinics and drug shops. PilPlan sales have increased steadily since
1993, but sales decreased slightly from 1998. It is not clear why, but consumers may be switching
to injectables.
CMS is the only organization socially marketing oral contraceptives. They “compete” only with
other types of pills supplied free from the public sector, including Lofemenal, which is essentially
the same product formulation as the Pilplan products. PilPlan has a 53% market share with 47%
other pills from the private sector. Sales are projected for 685,000 cycles in the year 2000.
Table 9: Sales History of PilPlan
Year Unit Sales
1993 66,026
1994 220,980
1995 309,743
1996 401,460
1997 517,860
1998 645,780
1999 625,860
Injectaplan
Injectaplan is a Depo-Provera product, supplied by USAID. Distribution was started in 1996, with
dramatic jumps in sales in 1998 and 1999. (See tables below.) Injectaplan is sold for 500 UgSH,
approximately 30 US cents, and is effective for a 3-month period. They come complete with an
injector, which must be brought to a qualified medical clinician, but this does not seem to be a
problem.
Sales were projected for 0% growth in 2000 , with 20,000 units a month expected to be sold. This
would mean target of 240,000 units in 2000. The current market share is 29%, with 71% through
the public sector.
45
Table 10: Sales History of Injectaplan
Year 1996 1997 1998 1999
Unit Sales 4,140 50,820 138,190 144,000
Other Products
CMS is currently marketing impregnated bednets through commercial outlets throughout the
country.
The are expecting to introduce on a pilot basis sales of an emergency contraceptive product
within a few months.
Summary
With regard to logistics, CMS is essentially an independent system. They forecast commodities,
arrange procurement through USAID, clear and warehouse products through Kampala
Pharmaceutical Industries, and distribute the products through the CMS system of sales agents.
An extensive marketing promotion supports the sales of these products.
Sales of Depo Provera are increasing dramatically, and can be expected to continue to increase.
Sales of oral contraceptives have shown a slight decrease in coming years. Sales of condoms have
increased regularly (taking into consideration major stockouts in 1999,) and can be expected to
continue to increase.
Because of the large volume of condoms, oral contraceptives and injectables that pass through the
CMS (and MSI) social marketing systems, their efforts increase availability and accessibility of
contraceptive products at all levels. In any national strategic planning, social marketing must be
calculated as part of overall commodity requirements, tracked as method mix and adjustments
made in forecasting and commodity procurement.
Recommendations:
1. Commercial Marketing Strategies should continue as part of the larger MOH FP logistics
stakeholders group to improve and expand on timely information sharing.
2. The NDA requires not only product registration, but packaging registration. Any changes in
packaging details must be registered as well. It will be important to insure all packaging
registrations are kept current to eliminate possibility of supply interruption because of
packaging or labeling issues.
3. USAID should inform CMS and NDA of any changes in product specifications or in
packaging and labeling information. This should be noted on the USAID NEWVERN
procurement tracking system notes.
4. USAID and CMS should crosscheck door-to-door payments made to Panalpina (the USAID
delivery agent) with clearance and final delivery costs paid to KPI.
46
Marie Stopes International - MSI Uganda
MSI- Uganda provides an extensive range of family planning services and counseling. Recently
they have become an active player in the social marketing of male and female condoms.
MSI started marketing male condoms in January 1997. The primary brand is Lifeguard, though a
smaller number of studded condoms are marketed under the Pleasure brand. Condom sales are
recorded in the tab le below.
Table 11: Sales History of LifeGuard Condoms
Year 1997 1998 1999 2000
Unit Sales 7,024,080 12,209,280 12,000,000 (estimate) 15,000,000 (target)
The Lifeguard condoms are produced by the LIG group/India and supported by KfW. The
condoms are sold in a packet of 3, for 100 Ugsh, the same as the CMS product. They are
overpackaged at the point of manufacture. The Lifeguard brand is supported by extensive
marketing and promotion campaigns.
Forecasting is done based on monthly sales, and sales figures are available for each outlet. Sales
projections for the year 2000 are targeted at 15 million condoms, a 25% increase. Sales figures
might be slightly skewed since CMS condoms were not available for the later half of 1999, so
sales should be tracked to be sure this 25% increase is not an over-projection. MSI tries to keep a
6-month stock-on-hand. Their supplies are kept at KPI warehouse and they do their own customs
clearance.
As with all other importers of condoms, MSI faced quality and clearance issues with the National
Drug Authority in 1999. This resulted in destruction of some condom supplies, stockouts and
slightly reduced sales in 1999 from 1998. These issues seem to have been resolved.
MSI has also been experimenting with the social marketing of female condoms. This started in
May 1997. Sales have slowly increased, with monthly sales averaging 200-800 a month, with
total sales as of Jan 1999 of 8,250 units. With low monthly sales and a total of 1.2 million
condoms brought into the country in 1997, there is an oversupply of female condoms at current
consumption rates and will probably expire.
As in other countries, the social marketing of female condoms is being done on a pilot basis. It
requires more extensive client and provider information and training than other products.
Summary
MSI maintains an independent logistics system for their male and female condoms. Forecasting,
clearance, warehousing, distribution and sales are done through their own separate systems.
However, their work impacts greatly on condom availability and accessibility. Between CMS and
MSI, 1999 sales were almost 15 million condoms, at a time of major condom stockouts for both
groups. With projected year 2000 sales for both groups, this is approximately 50% of the total
estimated condom use in Uganda.
47
Recommendations
MSI should be a part of an expanded stakeholders group so there is a up-to-date information
exchange about product availability, method mix and use in the country.
Use of female condoms should be tracked closely. It is likely that large quantities will expire in
2002, if consumption rates do not increase.
Private Sector Contraceptive Products
Beta Health Care markets the Durex brand condom, with 1999 sales of 120,000. Their cost per
condom is 833 UgSH (approximately 55 US cents each.) Since socially marketed condoms cost
33 UgSH each, this is designed for a specialized, upscale market. MacNoughton sells a Rough
Rider condom for the same price, with 1999 sales of 233,000. The market share for upscale
condoms is insignificant and should not effect public sector or socially marketed condom
projections.
No information is available for true private sector sales of oral contraceptives, but this market is
not being targeted by the public sector or by and socially-marketed product.
Family Planning Association of Uganda
The FPAU is the oldest family planning group in Uganda, having been operating for 48 years.
They have 28 branches in 23 districts, but will likely be consolidating with six regional centers
and a greater emphasis on community-based services. They provide both long-term and short tem
Family Planning choices, MCH ante and post-natal care, counseling and treatment for STI, post
abortion care and both prevention counseling and treatment for HIV/AIDS patients.
They provide a wide range of contraceptive products with an extensive method mix. They receive
many of their supplies through the IPPF, but can also acquire or purchase supplies locally. For
imported supplies, they do their own forecasting, procurement, clearing, warehousing and
shipment. They have a lorry for supply delivery, and use a private commercial company for
emergency shipments when necessary. Distribution to their clinics and outlets is by pull basis,
with distribution quarterly. They operate on a manual stock tracking system, and are interested in
a computerized system.
The consultants identified a large number of IUDS in FPAU possession, which would not have
been used and would expire in early 2001. Since the Ministry of Health was completely stocked
out of IUDS, and other programs such as MSI needed these immediately, a mutually beneficial
transfer of usable IUDS was arranged by the Reproductive Health Unit and started immediately.
This demonstrates the real value of an expanded stakeholders group, which could share
information and products across systems on a regular basis.
48
Recommendations
This section will group recommendations by the key responsible agency in order to help track
decisions and actions taken by each group. Some recommendations are duplicated since they will
apply to several agencies, in identical or similar ways. This also fulfills the requirement in the
consultant’s SOW to organize recommendations by individual implementing groups.
The Reproductive Health Unit of the Ministry of Health
A. Contraceptive Security – provision of adequate supplies – needs to be closely tracked,
especially as donors shift to Sector Wide Allocation programs. Continuity of supplies must be
ensured during this transition period and adequate contraceptive supplies included in the
SWAP budgeting. The Reproductive Health Unit, supported by donors and logistics technical
assistance, must be responsible for the inclusion of supplies planning. At the present time,
with ordered supplies included, there is at least a 2-year supply for most contraceptive
products. Now is the time to plan for beyond two years, using 2001 CPT projections.
Projections can be updated also with DHS data due in February 2001 and the Population
Consensus in 2002.
B. As allocations are made in the SWAP budgets, the RH Unit must work closely with the donor
agencies to be certain sufficient funding is included for contraceptive commodity
procurement and for their distribution. Since this is a new and evolving system, this process
must be tracked closely to monitor procurement funding levels. It would seem that the
Population Secretariat would be a useful ally in this process.
C. UNFPA funding will not be know until January 2001 at the earliest, so their possible support
must be calculated in then, if applicable.
D. The Reproductive Health Unit with external technical assistance should do CPT commodity
forecasting in July 2000 for the year 2001 and beyond. It should use all possible data sources
including demographic projections, DISH District survey data, 200 site dispensed to user data
and HMIS monthly form to produce projections.
E. We believe USAID will be able to support a two-week consultancy the end of July to have
technical assistance from FPLM to help conduct this extensive review and develop detailed
contraceptive need projections. FPLM technical assistance is also available at any time for
long-distance consulting or technical review on CPT forecasting or forecasting changes.
F. The Contraceptive Coordinating Committee should have a formal meeting every 4 months,
coordinated by the RH Unit. This would review stock-on-hand data, shipment coordination,
issues data, problems that arise, and information and product status that need to be shared.
This meeting should include all donors and potential donors, all social marketing distributors,
49
all providers of family planning services, the National Medical Stores and MOH sections
such as Reproductive Health, ACP, HMIS and the NDA.
G. Regular meetings would focus attention on stock status and future needs, identify problem
areas as they arise and permit information and even product exchange between stakeholders
to mutual advantage.
H. The Reproductive Health Unit should coordinate this meeting, but the DISH project has
generously offered to provide secretariat and other support to help coordinate this important
meeting. Having this meeting three times a year seems to be an effective timeframe in other
countries within the region.
I. Technical Assistance in Logistics planning and advocacy should be provided to the
Reproductive Health Unit from specialized external expertise and with on-going local
logistics support, primarily from the DISH project. This combination would strengthen the
capacity of the RH to coordinate forecasting, procurement and district level improvement.
The DISH II Project will provide technical assistance and funds to the district in improving
district level inventory control/ordering procedures and storage in the 12 DISH supported
districts.
J. External technical assistance under the direction of the RH Unit would be very productive to
help verify CPT forecasting, assist in the development of procurement guidelines, coordinate
improved District level inventory control and ordering procedures, improve storage
procedures, assist in the integration of logistics systems and bring in regional experience. If
this were able to be provided, the RH Unit could request specialized experience from within
the region or internationally. There is excellent regional expertise available from Nairobi,
which would be accessible on short notice.
K. The DISH project offers both advocacy and policy support and follow-up on the national
level and hands-on knowledge of logistics activities at the District and Health Unit level
within their 12 focus Districts. They will be conducting a detailed logistics survey in mid-
2000 and this knowledge will be useful for the RH Unit in planning District level systems and
approaches.
L. Specific project activities, including DISH, CARE, UNFPA and others, can be used to
promote RH Unit objectives is supporting logistics systems at the District level.
M. The ten percent handling fee on the value of commodities, due to the NMS for handling,
storing and shipping supplies to the District level, is such an obstacle to a smooth and
efficient ordering process that it should be made a guaranteed payment and taken out of the
ordering approval process.
Options to do this range from
1) RH securing guaranteed funding;
2) donors prepay this 10% when commodities are received by the NMS,
3) a guaranteed amount be authorized by line item in the Sector-wide planning budgets
or
4) a guaranteed amount be included in the Health Sector Debt-relief budgets.
district level ordering will not improve perceptively until this 10% handling fee issue
is resolved.
50
N. Immediately, the RH Unit should track their request for 272 Million Uganda Shillings for
commodity clearance which has been submitted to the Ministry of Finance. If this should not
be allocated, or if it is allocated in a significantly smaller amount, this information should be
shared with relevant donors to explore what other options might be possible.
O. The RH Unit should request from the NMS a detailed breakdown of the past unpaid and
anticipated 10% handling costs for contraceptive delivery so that the donor agency could
make provisions for this payment if possible.
P. RH and donors need to ensure dispensed to user data is maintained in the new HMIS forms.
Q. The HMIS forms are being revised at the moment. Logistics planning information is in
danger of being lost. Recommendations for the revised forms are attached in an appendix, but
the RH Unit and the donor organizations should track this development.
R. All contraceptive commodity importers must ensure that not only is the product registered
with the NDA, but that packaging and labeling must meet NDA specifications. Any changes
in packaging or labeling requires notification to the NDA.
S. if for any reason, USAID procured condoms are requested for the public sector in Uganda,
the RH unit must obtain in advance a waiver from the NDA for the importation of these
condoms.
T. If provided with a clear delivery order from the MOH and payment for services, the NMS has
the facilities, transportation and human resources to deliver contraceptive and other medical
supplies to the District level in a timely and efficient manner.
U. Dispensed to user data from a previously conducted 200 site survey should be entered and
analyzed. This work could be coordinated by the DISH project and be used in calculating the
2001 CPT report.
V. RH unit should use Pipeline software to assist in the procurement planning. This can be
installed by FPLM with training provided. Back-up technical assistance is always available
for the use of this system. Several individuals should be trained in Pipeline use.
W. Pipeline tracking of stock status would be a useful component of regular stakeholders
meetings.
X. The RH Unit can request technical assistance for contraceptive procurement in procedures,
specifications and quality control.
Y. RH and other key officials would benefit from the three-week Arlington logistics training
course. It would be important to develop a cadre of trained officials who could mutually
support the development of an improved logistics system. Two officials should be sent to the
next available training course.
.
51
I. RH and MOH Activities at the District and Health Unit Level
A. Expired Stock and damaged materials should be collected and removed from health unit and
District level storage areas. With prior notification to the Districts to collect expired products
to the District level; a truck could be sent to each district to collect expired contraceptive (and
drug) products. An authorized official from the MOH should be involved to receive, report
and sign for these products.
B. The NMS has developed a proposal for the removal of these expired products to the national
level.
C. Storage facilities need to be upgraded especially at the district level. The MOH should
encourage Districts and District-specific projects to provide minimal resources such as
shelving and paint to improve storage areas. One day’s worth of time to organize stocks and
train storekeepers in simple procedures would help substantially.
D. With the construction and re-furbishment of sub-district centers, simple plans for a functional
storage area could be developed. For example, built-in concrete shelves seen at some centers
were inexpensive and very effective. A minimum space requirement should be developed.
E. Basic storage job aides should be developed, disseminated and trained. This can be done with
FPLM and DISH assistance.
F. Procedures manual need to be developed for District and other level inventory control and
stock ordering. The Process should include the following:
- design workshop to achieve agreement on procedures and forms
- development of training manuals and on-the job training aids
- testing of training in DISH and other project areas
- inclusion of logistics training in other training packages
- training of both policy decision makers and operational cadre
- emphasis on dispensed to user data for decision making
G. This work should be coordinated with the drug project supported by DANIDA and forms.
Systems and approaches should be developed in common.
H. Contraceptive and other commodities need to be synchronized to the quarterly distribution
cycle of Essential Drug kits, once procedural obstacles are eliminated and staff trained to
manage inventory and ordering.
I. Define role of sub-District health center in logistics activities. The consultant’s initial
recommendation would be to avoid stock storage at this level.
J. Design and institute a system to re-distribute commodities in oversupply
52
USAID and Other Donor Organizations
A. Contraceptive Security – provision of adequate supplies – needs to be closely tracked,
especially as donors shift to Sector Wide Allocation programs. Continuity of supplies must be
ensured during this transition period and adequate contraceptive supplies included in the
SWAP budgeting. The Reproductive Health Unit, supported by donors and logistics technical
assistance, must be responsible for the inclusion of supplies planning. At the present time,
with ordered supplies included, there is at least a 2-year supply for most contraceptive
products. Now is the time to plan for beyond two years, using 2001 CPT projections.
B. As allocations are made in the SWAP budgets, the RH Unit must work closely with the donor
agencies to be certain sufficient funding is included for contraceptive commodity
procurement and for their distribution. Since this is a new and evolving system, this process
must be tracked closely to monitor procurement funding levels. It would seem that the
Population Secretariat would be a useful ally in this process.
C. Donor Procurement should involve the National Drug Authority in procurement planning,
especially with new commodities, new manufacturers or even new labeling, to avoid
clearance delays and possible exclusion of products. This should be done at the time of
commodity procurement, not when supplies have arrived in country.
D. USAID should consider providing support for specialized external technical assistance on a
regular basis
E. USAID should encourage and support DISH participation in logistics advocacy and policy
discussions and decisions at a national level. This would be a useful and effective use of
different aspects of USAID technical assistance.
F. USAID/Washington should note in the Newvern system (worldwide commodity procurement
tracking system) that any changes in product, manufacturers or packaging must be notified to
the NDA. And to USAID/Uganda.
G. USAID/ Washington should consider adding the Date of Manufacture to each condom
primary packet, at the time of the next worldwide production contract. This would comply
with WHO specification guidelines and conform to other condom labeling.
H. FPLM and USAID/Washington should send to NDA all agreed upon documentation and
FPLM should provide USAID-supplied products documentation and sample folder.
I. USAID/Washington should review shipping and payment instructions with Panalpina and
with Kampala Pharmaceutical Industries.
J. Donor Organizations and FPLM should encourage Uganda participation in RLI regional
logistics activities.
53
DISH Project
A. Use resources of DISH Project and other projects to advocate for, test and support
implementation of inventory and ordering capacity building at the District level.
B. Use Supply Chain Manager computer system for inventory control and ordering in DISH
Projects. Encourage expansion of logistics lessons learned in DISH focus districts to other
project-assisted Districts.
C. Provide a small fund for re-furbishment and improvement to District level storage areas and
provide training to storekeepers in simple storage improvements.
D. Support the RH Unit in encouraging and coordinating a stakeholders meeting for logistics
every four months at the national level.
Other Stakeholders
A. Actively Participate in a national-level logistics stakeholders meeting every four months.
B. Notify and receive approval from the National Drug Authority for product packaging and any
changes in product packaging.
C. There are a large number of female condoms in Uganda. With current levels of consumption,
there is more than a hundred years of supply. Even allowing for greatly improved
consumption rates; it might be advisable to consider “marketing” supplies that will not be
used to other countries.
54
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57
Appendix 1: Scope of Work
ASSESSMENT OF THE CONTRACEPTIVE LOGISTICS SYSTEM IN UGANDA
FAMILY PLANNING LOGISTICS MANAGEMENT PROJECT
Background
USAID/Uganda supports reproductive, maternal and child health programs in Uganda through
various strategies. These include increasing service utilization and behavior change by increasing
availability, improving quality, knowledge and perceptions and enhancing sustainability. In
addition, USAID supplies substantial contraceptive commodities for the entire country.
Availability of contraceptive supplies is an essential element in the delivery of quality, integrated
reproductive health services. Contraceptives in Uganda are procured through a limited number of
donors (USAID, UNFPA and DfID in particular) and provided to the Central Ministry of Health
(Reproductive Health Division) for their distribution to the District Health Offices and other
institutions responsible for service provision. Distribution from central to peripheral level
involves an intermediate storage step with the National Medical Store (NMS), a para-statal
institution responsible for drug purchase, storage and distribution at national level.
Over the last two years, repeated stock outs of contraceptive supplies have been registered at
national, district and facility levels. Several logistics issues that may possibly hamper the
programs’ success in ensuring that the products such as contraceptives are available for
distribution were identified, including:
Delays in-country procurement clearance resulting in a shortage of condoms and potentially
an expiration of expensive STI drugs and reagents due to outstanding handling fees owned to
the NMS.
Current limitations of donor coordination approaches, as shown by the unexpected
termination of Norplant supply by the UK.
The same distribution system is currently handling the all the free and cost-recovery products.
There is problem in ensuring that the products that are provided for free are used for the
intended purpose and not sold. It is difficult to achieve this, as the same products are also
available in the cost-recovery program.
Decentralization of health services has resulted in lack of information at the central level to
plan for procurement. In addition, it is also unclear whether there are sub-standard products
that have filtered in the system, due to lack of trained staff at the lower levels in procurement
procedures.
Poor quality of drugs/contraceptive storage and needs assessment at district and facility
levels.
Monitoring of CYP provided by the public sector institutions has shown a marked decrease
during 1999, when condoms went out of stock all over the country for more than six months and
injectable contraceptives showed a similar trend at the end of the year. While a shift towards the
58
private sector as the preferred source of contraceptive – at household level - may be taking place
currently and account for part of this trend, the MOH Reproductive Health office, USAID
Mission and the DISH Project are worried that potential stock outs of contraceptive and other
supplies may prevent the achievement of the objectives of increased availability and quality of
reproductive health services. Within this context, they would like to request the Family Planning
Logistics Management Project to conduct, in coordination with MOH, DISH, CMS and other
partners, a systematic assessment of the contraceptive procurement system in Uganda.
Goal of the Assessment
To conduct a qualitative and quantitative assessment in order to formulate recommendations to
improve the efficiency of the logistics system based on the data gathered on the current status of
the contraceptive logistics system. The assessment will include the complete in-country supply
chain, i.e. all tiers of the system and will review all functions of logistics; procurement,
distribution, transportation, warehousing, inventory control and LMIS.
While the assessment will focus on the contraceptive logistics system, where feasible, the team
will also collect data on logistical aspects of essential drugs, vaccines, vitamin A, iron
supplements, STD drugs, TB drugs, drugs for opportunistic infections related to AIDS and other
public health commodities.
Specifically, the assessment will provide an understanding of the comprehensive issues with the
current contraceptives logistics system in Uganda and provide at set of specific recommendations
to facilitate an adequate and timely supply of contraceptives over the coming five years.
Objectives of the assessment
1. To assess the status and function of the logistics-based activities of key partners at all
levels of Uganda supply chain for reproductive health supplies and critically review the
current structure of the various supply chains currently operating in Uganda , with
particular attention brought to the following issues/problems:
- past procurement patterns, intentions of current donors and availability of
funding over the coming five years;
- Ministry of Health intentions/plans with regards to contraceptive procurement
with national/district funds and proposed move towards a “pull” drug
procurement system;
- relationships between the various institutions (MOH, NDA, NMS, JMS, CMS,
districts and others) involved in storage and distribution of donor-procured
contraceptive supplies, in particular with regards to:
- legal requirements for importation/packaging of pharmaceutical
products, in particular contraceptive supplies
- responsibilities of central MOH and districts vis-à-vis storage and
handling fees
- definition of procedures for procurement of contraceptives from the
district level (that is, which institution is responsible for supplying the
districts and facilities?)
- adequacy of the current contraceptive needs assessment process at national and
district levels
- the perception and position of the National Drug Authority about social
marketing and community-based distribution programs, and the problems faced
59
by these subsidized programs in the procurement, clearance and distribution of
contraceptives with respect to the requirements of the NDA
- existing contraceptive logistics and management practices and networks of CMS,
Marie Stoppes and FPAU with respect to the established MOH drug logistics and
management system
- adequacy of existing human resource at the MOH for performing its core
functions related to drug/contraceptives logistics and management.
2. To gather and review logistics indicators for all levels of the MOH system for
contraceptives
3. To identify the main causes of recurrent stock outs of contraceptive supplies, identify
areas that need to be strengthened or streamlined in order to improve the flow of the
product through the systems and suggest operational solutions to ensure the timely and
sufficient provision of these supplies through the coming five years.
4. To estimate, from a review of the previous Contraceptive Procurement Tables and from
the findings of the assessment, the needs for contraceptive supplies over the next years,
both at national level and in the 12 DISH and 3 CARE districts (based on a 1% projected
annual increase in CPR at national level and 1.5% in the DISH-supported districts.
5. In addition, the assessment team should help the DISH Project identify those
issues/problems/ constraints related to contraceptive procurement that are equally
relevant to the overall drug procurement system in Uganda; and provide advice, based on
its experience in this area, on the feasibility of extending the current computerized
commodity tracking system to a wider range of products (in particular, IMCI-related
drugs, Vitamin A, Iron, vaccines and other selected public health commodities).
Planned Output of the Assessment
1. A report on the status of the current funding, procurement, clearance, storage,
distribution, sales and LMIS for contraceptive supply in Uganda and existing failures or
constraints.
2. An estimate of the quantities of contraceptive supplies (per method) needed over the next
five years for the country, and for the DISH and CARE-supported districts.
3. A set of operational recommendations aimed at facilitating an adequate and timely supply
of contraceptives over the coming five years; these recommendations should be
specifically directed to:
- the USAID Mission
- the Ministry of Health and other government or parastatal institutions involved
- the DISH Project
- the CMS Project
Timing and duration
It is agreed that the study shall begin on May 1 for a duration of three weeks.
Assessment Team
Two FPLM staff will work in collaboration with the MOH, DISH-II project and other donor
partners to conduct the assessment. Prior to the arrival of the FPLM staff, DISH-II will assist in
60
gathering some preliminary data, help with setting up a schedule for the team, identify the sample
size and participating on the team itself.
The team will also work closely with Bonita Blackburn/USAID/W to coordinate the resolution to
the procurement issues and their potential impact to the contraceptive logistics system.
Methodology/Strategic framework of the Assessment
The assessment will gather qualitative data through key informant interviews and quantitative
indicators to assess the overall status of the logistics system. The logistics cycle will be used as a
framework. Data will be collected on the entire in-country supply chain from the central level, all
the way to the clinic where the product is dispensed to the client.
In addition to the standard assessment, the team will use the Logistics Performance Matrix
1
used
by many private sector companies to assess the performance of each of the components of the
logistics system and of the overall status of the supply chain performance. Performance indicators
will be gathered where possible on Quality, Productivity and Response Time on each of the
activities of the logistics system. This data will inform managers, operators, and designers on
their current performance in each of the logistics activity and enable them to set targets to
improve the logistics system. If the data can be gathered, it can be used to at least set up an
internal benchmarking program among the different regions or districts.
Note: the DISH Project plans to conduct in May and June 2000 a district-level assessment of the
drug logistics systems which should complement the proposed assessment, as well as the Drugs
for Management of Childhood Illnesses (DMCI) study undertaken by the Rational
Pharmaceutical Management (RPM) Project. Accordingly, the FPLM team may focus its efforts
on national and central level logistics and management issues.
Focal Persons
Dr. Vincent David of DISH-II and Ms Annie Gaboggaza-Musoke of USAID will be the focal
person to oversee the implementation of this assessment. Before and during the assessment, the
DISH Project staff will also identify and make appointments with relevant persons and
institutions; review the trends of past funding of contraceptive supply in the country; compile
existing literature on drug procurement
studies in Uganda and brief FPLM team upon arrival.
Addendum for Bonita Blackburn, USAID/W
It is our understanding the Ms Bonita Blackburn from USAID/W will join the FPLM team. We
would like to take the golden opportunity to increase common understanding and expectation
among USAID/W, USAID/Uganda and sleeted USAID implementing partners including CMS
and DISH about CPTs and critical issues with NDA regarding procurement, clearance and
distribution of drugs and contraceptives. Accordingly, we would appreciate that Ms Blackburn:
1) review and discuss CPTs and related problems and recommend revisions USAID and CMS
2) review and revise roles and responsibilities for development and monitoring of CPTs with
USAID and CMS
1
Frazelle Edward, Logistics Performance, Cost and Value measures. 1999. Penton Media Inc.
61
3) Familiarize her with NDA procedures and pitfalls,
4) Present USAID procurement to NDA and the MOH with CMS
5) review shipping documents and procedures with USAID,KPI and CMS).
Proposed Institutions to be contacted/visited
Government institutions
Ministry of Health
Headquarters of the Ministry of Health: responsible for policy formulation, implementation and
supervision. This will include clinical services, Pharmaceutical division. Reproductive Health
project, Logistics section, etc.
NMS – National medical stores: A parastatal drug procurement and distribution corporation,
involved in the handling, storage and distribution of drugs and contraceptives mainly for the
public sector.
Ministry of Local Government – Decentralization secretariat: Oversees district health services
under the decentralization scheme.
Uganda Local Authorities Association
NDA – National Drug Authority: The national drug regulatory agency. Formulates drug policies,
regulates drug imports, drug use, issues national drug use guidelines and sets standards.
Uganda Peoples Defense Forces
Service delivery centers including Hospitals (including Mulago, Regional District referral,
District, NGO, HC IV, HC III, HC II)
Donors
DANIDA: Funds health related programs like Health sector support program (HSSP) and
essential drugs support program (EDSP)
UNFPA Funds the Reproductive Health (RH) project that carries on Reproductive health
services in about 26 districts. Funds substantially the supply of contraceptives in the country
EDSP Funded by DANIDA. Funds rural drugs/drug kits
DfID Funds procurement of contraceptives. Supports collection of data needed for
contraceptive projections
USAID
Projects/NGOs
HSSP: Supports the training of medical assistants & equipping paramedicals, supports
implementation of HMIS and supports the quality assurance unit
62
STIP – Sexually Transmitted Infections Project: Funded by among others the World Bank. It
operates countrywide. It is involved in the prevention of sexually transmitted diseases, care
for the people with AIDS and the other related diseases.
DHSP – District Health Services Program: Funded by World Bank, KfW, SIDA, and GoU.
Supports capacity building in district primary health care services.
JMS - Joint Medical Stores: Christian founded drug procurement NGO involved in drug
storage and rational drug use promotion.
CMS – Commercial Market Strategies: involved in social marketing of condoms, oral and
injectable contraceptives, STI treatment kits.
MSI - Marie Stoppes International: CNS competitor, also involved in social marketing of
contraceptives
Others
Districts- Involved in drug logistics and management
KPI – Kampala pharmaceuticals industries: Manufacture of drugs, packaging of commodities
e.g. protector condoms for CMS.
Association of Drug Importers
WHO - Involved in various fields: PHC, disease control, malaria and tropical diseases,
women and children health, health information, nutrition, environmental health, non-
communicable diseases. Very influential on MOH policy development and standard setting
63
Appendix 2: The Logistics Cycle
Product Selection
Procurement
Use
Distribution
Management Support
Organization
Finance
Information Management
Human Resources
64
Appendix 3: Schedule for FLM/USAID Assessment Team
May 2 – 19
th
, 2000
Tuesday, May 2
8:30am USAID Kampala briefing
Angela Lord, Rebecca Rohr, Annie Kaboggoza-Musaki, Betty Nabirumbi
10:30am Reproductive Health Unit
Dr. Florence Ebanyat, Dr. E.F. Katumba, Dr. Bazirake (UNFPA)
1:30pm DISH II Project
Dr. Vincent David, Eldad Sebagenzi, Dr. Stembile Matutu, Charles Katende
3:15pm Kiswu Clinic, Kampala
Daisy Okuma
4:00pm STI Project
Dr. Peter Nsubugu
Wednesday, May 3
8:30am DISH II Project
Dr. Souleymane Barry, Dr. Vincent David, Eldad Sebagenzi
11:00am Commercial Marketing Strategies (CMS)
Elizabeth Gardner
1:30pm National Drug Authority
Dr. John Lule, Francis Otim, Gabriel Kaadu
4:00pm DFID
Ros Cooper
Thursday, May 5
8:30am USAID
Angela Lord, Rebecca Rohr, Betty Nabirumbi
9:30am UNFPA
Fabian Byomuhangi
11:30 CMS
Dr. Peter Crowley, Elizabeth Gardner, Rebecca Rohr
2:00pm HSSP/DANIDA Project
Sjoerd Postma
Friday, May 5
9:00am National Medical Stores, Entebbe
Patrick Kisitu, Saul Kidde, David Kubagenda
3:30pm Marie Stopes Intl.
Judith Butagira
4:30pm DISH II Project
David Vincent
6:00pm Regional Quality of Care Center – Makerere U.
Shelia Magero, Tom Kakaire
Monday, May 8
9:00am USAID
John Cutler
10:30am DISH II
Muyingo Sowedi
65
1:30pm Joint Medical Stores
Wim Mensink
3:30pm Uganda Midwives Association
Charlotte, Gideon Nzoka
4:30pm Family Planning Association of Uganda
Dr. Paul Kabwa
Tuesday, May 9
9:00am DMS, Ministry of Health
Professor Omaswa, Dr. Ebanyat
11:00pm Depart for field
3:00pm Kamuli District Office
DHV, Nurse, Storekeeper
4:30pm Level Four Clinic
Kamuli Nurse, Storekeeper
Wednesday, May 10
9:00am Pallisa District Office
DHO, Nurse, storekeeper
11:30am Buseta Clinic – Level III
Doctor, nurse, storekeeper
3:30pm Mbale District Office
DMO, nurse, storekeeper
4:30pm UNFPA Regional Office
Regional coordinator
Thursday, May 11
9:00am Budadiri Clinic Level III
Doctor, nurse, storekeeper
11:30am Buwalasi Clinic Level IV
DDHS, nurse, storekeeper
1:30pm Iganga District Office
Nurse, storekeeper, records
3:00pm Muyunge Health Center –III
Doctor, nurse, storekeeper
Friday, May 12
9:30am DISH II Project
Souleymane Barry, Muyingo Sowedi
11:00pm USAID
Betty Nabirumbi, Annie Kaboggoza-Musaki
2:00pm USAID
Dawn Liberi, Patrick Fleuret, Angela Lord
Monday, May 15
9:00am World Bank
Peter Okwero
10:30am CARE
Louis Alexander, Dr. T. Makwate
66
Tuesday, May 16
9:00am NMS- Inventory Count
Saul Kidde, David Kubagenda
1:30pm UNEPI
Isingoma Patrick, Winifred Tabaaro, Zura Asander, Kurasi Beim
2:30pm Geographic Mapping Survey Department
Wednesday, May 17
9:00am Ministry of Finance
Magona Ishmael, Steve Rice, Annie Kaboggoza-Musaki, Betty Nabirumbi
11:00pm USAID
Patrick Fleuret, Angela Lord, Anne Kaboggoza-Musaki, Betty Nabirumbi, John
Cutler
6:00pm Regional Center
Joel Okullu
Thursday, May 18
10:00am Population Secretariat
Dr Jotham Musinguzi, Nahabwe Paddy, Rhobbinah Ssempebwa
Charles Zirarema,
11:30am CMS
Peter Crowley, Elizabeth Gardner, Sarah Margiotta, Angela Lord, Annie
Kaboggoza-Musaki.
10:00am Reproductive Health
Dr. Katumba
2:00pm Stakeholders Meeting
Dr. Mbowye, Dr. Katumba, Karl Kulessa, Dr. Bazirake, Ros Cooper, James
Thornberry, Annie Kaboggoza-Musaki, Betty Nabirumbi, John Cutler, Dr.
Souleymane Barry, Muyingo Sowedi, Dr. Vincent David, Chris Forshaw, Dr.
Joel Okullo, Wim Mensink, Elizabeth Gardener, Sarah Margiotta, Steve Wilbur,
Sangeeta Raja
Friday, May 18
9:00am Reproductive Health Unit
Dr. Katumba
11:00am USAID
Angela Lord, Annie K., Betty N.
11:30am DFID
Ros Cooper
12:00pm DISH II Project
Souleymane Barry, Muyingo Sowedi
67
Appendix 4: People Contacted
Uganda country code: 256 Kampala: 41 Entebbe:
Ministry of Health
P.O. Box 7272, Kampala, Uganda
Tel: 256-41-231563/9
Fax: 256-41-340881
Title Name Email Contact Number
Director General Health
Services
Francis D. Omaswa [email protected] Tel: 340881
Assistant Commissioner,
Reproductive Health
Dr. Florence Ebanyat [email protected] Mob: 077 413485
Principal Medical officer Dr. E.F. Katumba Tel: 340874
Project Manager (STIP) Dr. Peter Nsubuga [email protected]
Tel: 340884
Fax: 340877
Ministry of Finance, Planning & Economic Development
Infrastructure & Social Services Dept.
P.O. Box 8147,Kampala, Uganda
Tel: 256-41-235051/4
Fax: 256-41-251793
Assistant Commissioner Magona Mweru Ishmael [email protected]
Health Economist Steve Rice [email protected] Mob: 077 469511
Ministry of Finance, Planning & Economic Development
Population Secretariat
Crane Chambers
Plot 38 K’la Rd.
P.O. Box 2666, Kampala, Uganda
Tel: 256-41-342292
Fax: 256-41-343116
www.uganda.co.ug/population
Director Dr. Jotham Musinguzi [email protected] 343356
National Programme
Officer, Head Socio-
Economic Monitoring
Dept
Nahabwe W. Paddy [email protected] Mob: 077 420446
National Programme
Officer, Head Family
Health Dept.
Rhobbinah Ssebbowa
Ssempebwa
[email protected]
National Programme
Officer, Head policy &
Planning Dept.
Charles Zirarema [email protected] Mob: 077 456011
USAID/Uganda
Plot 42 Nakesero Rd
Kampala, Uganda
Tel: 256-41-235879
Deputy Mission Director Patrick Fleuret [email protected]
Chief, Office of
Population, Health and
Nutrition
Angela Lord [email protected] Mob: 077 221228
Rebecca
Annie
Project Management
Assistant
Betty Nabirumbi [email protected]
Senior Health Advisor Dr. John Cutler [email protected] Mob: 075 721101
68
DISH
Plot 20 Kawalya Kaggwa Close
Kololo
P.O. Box 3495, Kampala, Uganda
Tel: 256-41-344075
Fax: 256-41-250124
Chief of Party
Dr. Souleymane
Martial L. Barry
[email protected]
Health
Management/Quality
Assurance Advisor
Dr. Vincent David [email protected] Mob: 077 221324
Research & Evaluation
Advisor
Charles M. Katende [email protected] Mob: 077 409756
Logistics/Financial
Management Specialist
Muyingo Sowedi [email protected] Mob: 075 652862
Planning/Management
Coordinator
Eldad Sebagenzi Mob: 077 458324
National Medical Stores
plot 4-12 Wilson Rd
P.O. Box 16, Entebbe, Uganda
Tel: 256-41-321323
Fax: 256-41-321469
Ag. General Manager Patrick Kisitu [email protected] Mob: 077 771336
Head Stores/Logistics Saul Kidde [email protected]
Stores Supervisor David Kubagenda
HSSP
MOH/DANIDA
MOH Complex
Plot 6 Lourdel Rd.
Kampala, Uganda
Tel: 256-41-235477
Fax: 256-41-235478
Chief Technical Advisor Sjoerd Postma [email protected]
HSSP
MOH/DANIDA
National Drug Authority
Plot 93
Buganda Rd
P.O. Box 23096,Kampala, Uganda
Tel: 256-41-255665
Fax: 256-41-255758
Pharmaceutical Advisor Chris Forshaw [email protected] Mob: 075 760175
UNFPA
Commercial Plaza, 3
rd
Fl
Plot 7 Kampala Rd
P.O. Box 7184, Kampala, Uganda
Tel: 256-41-345600
Fax: 256-41-236645
Deputy Director Karl Kulessa [email protected]
Commercial Marketing Strategies
Plot 16 Seibwa Rd
Nakasero
P.O. Box 27659, Kampala, Uganda
Tel: 256-41-230283
Fax: 256-41-258678
Country Director Peter Cowley [email protected] Mob: 077418294
Social Marketing director Elizabeth Gardiner [email protected] Mob: 077431911
Logistics/MIS Manager Sarah Margiotta [email protected] Mob: 075640563
69
MSI – Uganda
Plot 1020 Kisugu, Muyenga
P.O. Box 3557, Kampala, Uganda
Tel: 256-41-267587
Fax: 256-41-268756
Project Director Judith Butagira [email protected]
The World bank
Rwenzori House
1 Lumumba Ave.
4 Nakesoro Rd/
P.O. Box 4463, Kampala, Uganda
Tel: 256-41-236825
Fax: 256-41-230092
Health Specialist Dr. Peter Okwero [email protected]
Joint Medical Stores
P.O. Box 4501, Kampala, Uganda
Tel: 256-41-266126
Fax: 256-41-267298
Manager Wim A.C. Mensink [email protected]
FPAU
Plot 2 Katego Rd.
P.O. Box 10746, Kampala, Uganda
Tel: 256-41-540658
Fax: 256-41-540657
Executive Director Paul B. Kabwa [email protected] Mob: 075 701953
Pallisa District Local Government
P.O. Box 14
Pallisa, Uganda
Tel: 40
District Director of Health
Services
Dr. Namonyo Andrew Mob: 077 441522
CARE International/Uganda
17 Mackinnon Rd.
Nakasero
P.O. Box 7280, Kampala, Uganda
Tel: 256-41-235880
Fax: 256-41-344295
Assistant Country
Director Program
Louis Alexander [email protected] Mob: 077 221103
Health/Education Sectors
Advisor
Dr. Tumwebaze Lorna
Makwate
[email protected] Mob: 077 412361
DfiD
Ruwenzori Courts
Tel: 256-41-348 728
Fax: 256-41-
Health Coordinator Ros Cooper Mob: 077 443 239
James Thornberry
doc_331632105.pdf
The logistics systems for all health commodities present a tangled picture, with overlapping systems and information, as well as public sector and private sector players. This report focuses on family planning commodities logistics, while recording other systems and identifying their existing and potential relationships with contraceptive provision systems.
Uganda Logistics Systems for Public
Health Commodities: An Assessment
Report
May 1 – 21, 2000
Final Report
Prepared by:
Sangeeta Raja, Steve Wilbur and Bonita Blackburn
John Snow Inc./Family Planning Logistics Management (FPLM)
United States International Development Agency/Washington
Contributors:
Ministry of Health/Uganda
United States International Development Agency/Uganda
Delivery of Improved Services for Health Project II
2
FPLM
The Family Planning Logistics Management (FPLM) project is funded by the Office of Population of the
Bureau of Global Programs of the U.S. Agency for International Development (USAID). The agency’s
Contraceptive and Logistics Management Division increases the awareness, acceptability, and use of
family planning methods, and expands and strengthens the managerial and technical skills of family
planning and health personnel.
Implemented by John Snow, Inc. (contract no. CCP-C-00-95-00028-04), the FPLM project works to ensure
the continuous supply of high quality health and family planning products in developing countries. FPLM
also provides technical management and analysis of two USAID databases, the contraceptive procurement
and shipping database (NEWVERN), and the Population, Health, and Nutrition Projects Database (PPD).
This document does not necessarily represent the views or opinions of USAID. It may be reproduced if
credit is given to FPLM.
Recommended Citation
Raja, Sangeeta, Steve Wilbur and Bonita Blackburn Uganda Logistics System for Public Health
Commodities: An Assessment Report. 2000. Published for the U.S. Agency for International Development
(USAID) by the FPLM project. Arlington, Va.
FPLM
Family Planning Logistics Management
John Snow, Inc.
1616 North Fort Myer Drive, 11
th
Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
E-mail: [email protected]
Internet: www.fplm.jsi.com
3
Acknowledgements
The Family Planning Logistics Management project (FPLM) of John Snow, Inc. wishes to
acknowledge the contributions of the following organizations who provided time, staff and data
to assist in completing the assessment:
ORGANIZATIONS
• ACP
• CARE
• CMS
• DANIDA
• DFID
• DISH II
• FPAU
• Iganga District
• HSSP
• JMS
• Kamuli District
• Mbale District
• MOF
• MOH - Health Services
• MOH - Reproductive Health
• MOH - Resource Planning
• MSI
• NDA
• NMS
• Pallisa District
• Population Secretariat
• RTC
• STIP
• Survey Department
• UNEPI
• UNFPA
• USAID
• World Bank
A special thank you goes to the U.S. Agency for International Development (USAID)/Uganda,
the Ministry of Health and the Delivery of Improved Services for Health (DISH) II project, who
provided valuable input and support in completing the assessment.
We are particularly grateful to the U.S. Agency for International Development (USAID)/REDSO
Mission for funding the assessment.
Finally, we would like to thank everyone we have met during the assessment and who are too
numerous to mention. All of them have given their time and information freely, and their
dedication to providing the best possible service to the people of Uganda has guided and
encouraged the suggestions in this report.
As always, the recommendations in this document are those of the consultants, but are based on
the collective experiences of the FPLM project and on the wisdom and ideas of those working on
a day to day basis within Uganda. We hope (trust) that these recommendations will be helpful in
improving logistics system and are prepared to work with all parties to implement the suggested
improvements.
4
5
Table of Contents
Acknowledgements ....................................................................................................................................... 3
Acronyms....................................................................................................................................................... 7
Executive Summary...................................................................................................................................... 9
Key findings ............................................................................................................................................... 9
National Level........................................................................................................................................ 9
District and Health Facility Level ........................................................................................................ 10
Recommendations .................................................................................................................................... 11
National Level...................................................................................................................................... 11
District and Health Unit Level ............................................................................................................. 13
Situation....................................................................................................................................................... 15
Objectives: ................................................................................................................................................... 16
Methodology................................................................................................................................................ 16
Background ................................................................................................................................................. 17
Ministry of Health Organization and Structure ........................................................................................ 17
Sector Wide Approach ............................................................................................................................. 18
Public Health Supply Chain Systems ....................................................................................................... 18
Logistics Systems for the Management of Public Health Supplies .......................................................... 21
Essential drugs ..................................................................................................................................... 21
Contraceptives...................................................................................................................................... 21
Uganda National Expanded Project on Immunization (UNEPI).......................................................... 22
Integration Possibilities........................................................................................................................ 22
Product Selection ........................................................................................................................................ 23
Procurement ................................................................................................................................................ 26
Forecasting ............................................................................................................................................... 26
Donor Coordination.................................................................................................................................. 28
Drug Regulation and Importation............................................................................................................. 28
Product Review with NDA....................................................................................................................... 29
Distribution.................................................................................................................................................. 31
Warehousing............................................................................................................................................. 31
National Medical Stores....................................................................................................................... 31
Ordering.................................................................................................................................................... 33
Ordering and Delivery processes from the National Medical Stores ................................................... 33
Ten Percent Handling Charge .............................................................................................................. 35
Inventory Control at the NMS.................................................................................................................. 37
Expired Products handling at the NMS level............................................................................................ 38
Joint Medical Stores ................................................................................................................................. 38
Transportation............................................................................................................................................ 38
6
Logistics Management Information System............................................................................................. 39
Forms Used in the System........................................................................................................................ 39
Impact of MOH Changes to HMIS Forms................................................................................................ 41
Social Marketing for Contraceptive Products.......................................................................................... 42
Commercial Market Strategies (CMS) ..................................................................................................... 43
CMS Condoms..................................................................................................................................... 43
Oral Contraceptives.............................................................................................................................. 44
Injectaplan............................................................................................................................................ 44
Other Products...................................................................................................................................... 45
Summary.............................................................................................................................................. 45
Recommendations: ............................................................................................................................... 45
Marie Stoppes International - MSI Uganda............................................................................................. 46
Private Sector Contraceptive Products ..................................................................................................... 47
Family Planning Association of Uganda ................................................................................................... 47
Recommendations....................................................................................................................................... 48
The Reproductive Health Unit of the Ministry of Health......................................................................... 48
USAID and Other Donor Organizations................................................................................................... 52
DISH Project ............................................................................................................................................ 53
Other Stakeholders ................................................................................................................................... 53
Bibliography................................................................................................................................................ 54
Appendix 1: Scope of Work..................................................................................................................... 57
Appendix 2: The Logistics Cycle ............................................................................................................. 63
Appendix 3: Schedule............................................................................................................................... 64
Appendix 4: People Contacted ................................................................................................................. 67
7
Acronyms
ACP AIDS Control Programme
CBD Community Based Distribution
CMS Commercial Marketing Strategies
CYP Couple Year Protection
DANIDA Danish International Development Assistance
DDHS District Director for Health Services
DHMT District Health Management Team
DHV District Health Visitor
DfID Department for International Development
DISH Delivery of Improved Services for Health
FPAU Family Planning Association of Uganda
GoU Government of Uganda
HMIS Health Management Information System
HSSP Health Sector Strategic Plan
IPPF International Planned Parenthood Federation
JMS Joint Medical Stores
KfW Kreditanstalt fur Wiederaufbau
KPI Kampala Pharmaceutical Industries Ltd.
MOF Ministry of Finance
MOH Ministry of Health
MSI Marie Stopes International
NDA National Drug Authority
NMS National Medical Stores
RLI Regional Logistics Initiative
STIP Sexually Transmitted Infections Project
SWAP Sector Wide Approach
UDHS Uganda Demographic and Health Survey
Ugsh Ugandan Shillings
UEDSP Uganda Essential Drugs Support Programme
UNEPI Ugandan National Expanded Programme for Immunization
UNFPA United Nations Population Fund
USAID United States Agency for International Development
WB World Bank
WHO World Health Organization
8
9
Executive Summary
The logistics systems for all health commodities present a tangled picture, with overlapping
systems and information, as well as public sector and private sector players. This report focuses
on family planning commodities logistics, while recording other systems and identifying their
existing and potential relationships with contraceptive provision systems. There are national level
issues to be addressed, and district and other health facility levels issues that require
improvement. This report uses the components of the logistics cycle to track systems and make
recommendations based on national and district level needs.
These findings and recommendations were presented and discussed during a stakeholders
meeting with a large number of key players in Uganda at the conclusion of the consultancy. They
are presented here in bullet form as a brief summary of information presented in more detail in
the rest of the report. The recommendations are presented in more detail at the end of the report,
organized by agency for easier tracking.
Key findings
National Level
General
• Public health commodities reach the customer through several separate logistics systems.
These include MOH, CMS, MSI, JMS, FPAU, UNEPI and the private sector.
• Some aspects of the logistics system in the MOH are integrated while others are managed
separately. Systematic integration of the supply chains could result in cost and time-savings
and improve product availability and efficiency at the service delivery level.
Product Selection
• Essential drugs are selected from the essential drug list and the standard treatment guidelines.
• The donors and the RH unit select a wide range of short and long term contraceptive methods
based on family planning policy guidelines.
Procurement
• Importation regulation according to the NDA statute resolved.
Forecasting
• Capacity of the RH unit extended and manpower not sufficient.
• Many data sources available for projection – but none are complete.
• Consumption not known at the national level.
• New changes proposed in the new HMIS forms will make forecasting even more difficult.
• Donor coordination meetings taking place – need to extend its role to include review of all
logistics issues.
Warehousing
• NMS has the capability to manage the distribution and warehousing to pharmaceuticals.
• 100% match of the physical count with the computerized inventory at NMS.
10
• 10% handling fee at the NMS contorts the delivery system – resulting in delay in delivering
district supplies from 3 weeks to 3 months.
• Inventory control computerized and managed at the NMS.
• Responsible programme in MOH notified 6 months prior to the expiration of any product.
Transportation
• Drugs being delivered to all 45 districts every quarter based on a set schedule.
• Deliveries occur within 1 week of the scheduled date.
LMIS
• Service statistics reported by the districts to the central level.
• Data used to revise the kits
• HMIS database managed at the central level. Data includes aggregated service statistic
reported by the districts.
District and Health Facility Level
Procurement
• Small amounts of drugs bought from local suppliers using user-charge fees.
• Perceive quality of drugs to be better and more reliable from the NMS.
Forecasting
• No forecasting currently done at the district level.
Warehousing/Storage
• No basic shelving in most of the stores in the districts visited – difficult for the storekeeper to
organize and distribute products.
• Storekeepers not trained in basic storekeeping procedures.
Inventory control
• Contraceptive stock cards not kept up to date.
• Lack of inventory control and management.
• Lack of ordering skills to base orders on max and min.
• Lack of skill to calculate months of stock available.
• Too many progesterone-only pills in the facilities visited. Large stock of VFT at all levels.
• Stocks not ordered until total stockout.
• When the stocks are ordered, various methodologies are used to determine the order quantity,
(consumption, service statistics, guess work).
• Most facilities visited had at least 2 – 3 contraceptives that were stocked out at the time of the
visit.
• Procedure manual not available.
Transportation
• Essential drugs and vaccines delivered to the clinics.
• Local initiative by staff from both the clinic and the district level manage to arrange the
transport to deliver/collect the supplies.
11
LMIS
• Essential data (stock on hand, dispensed/issued, adjustments/losses) collected at different
places by different people, but not synthesized and not used for decision-making.
• Reports sent to HQ incomplete or delayed (3-6 months).
• Districts have initiated report tracking. This has improved the reporting timeliness.
Use
• Reported increase in the use of Depo Provera
• Low consumption of PoP, IUD, and VFTs.
• User fees for family planning services applied differently at each health facility.
Human Capacity
• Most of the staff do not have training in logistics.
• Roles and responsibilities of each staff involved in the management of the logistics system
not clarified or documented.
Recommendations
National Level
A. The Reproductive Health Division with external technical assistance should do CPT
commodity forecasting in July 2000 for the year 2001 and beyond. It should use all possible
data sources including demographic projections, DISH district survey data, 200 site dispensed
to user data and HMIS data to produce short and long term projections.
B. Contraceptive Security – provision of adequate supplies – needs to be closely tracked,
especially as donors shift to sector wide approach programs. Continuity of supplies must be
insured during this transition period and adequate contraceptive supplies included in the
SWAP budgeting. Reproductive Health Division and donors, supported by logistics technical
assistance, must be responsible for the inclusion of supplies planning. At the present time,
with ordered supplies included, there is at least a 2-year supply for most contraceptive
products. Now is the time to plan for beyond two years, using 2001 CPT projections.
C. The Contraceptive Coordinating Committee should have a formal meeting every 4 months,
coordinated by the RH Division. The meeting would review stock-on-hand data, shipment
coordination, issued and dispensed to user data, problems that arise, information and product
status that need to be shared. This meeting should include all donors and potential donors, all
social marketing distributors, all providers of family planning services, the NDA, National
Medical stores and MOH sections such as Reproductive Health, Planning unit resource centre
and ACP.
D. Donor procurement should involve the National Drug Authority in procurement planning,
especially with new commodities, new manufacturers or even new labeling, to avoid
clearance delays and possible exclusion of products.
E. All contraceptive commodity importers must ensure that not only is the product registered
with the NDA, but that packaging and labeling must meet NDA specifications. Any changes
in packaging or labeling requires notification to the NDA.
12
F. USAID/Washington should note in the Newvern system that any changes in product,
manufacturers or packaging must be notified to the NDA.
G. USAID/ Washington should consider adding the Date of Manufacture to each condom
primary packet, at the time of the next worldwide production contract. This would comply
with WHO specification guidelines and conform to other condom labeling.
H. FPLM and USAID/Washington should send to NDA all agreed upon documentation and
FPLM should provide a USAID-supplied products documentation and sample folder.
I. USAID/Washington should review shipping and payment instructions with Panalpina and
with Kampala Pharmaceutical Industries.
J. Technical assistance in logistics planning and advocacy should be provided to the
Reproductive Health Division from specialized external expertise and with on-going local
logistics support, primarily from the DISH II project. This combination would strengthen the
capacity of the RH to coordinate forecasting, procurement and district level improvement.
K. If for any reason, USAID procured condoms are requested for Uganda for the public sector,
the RH Division must obtain in advance a waiver from the NDA for the importation of these
condoms.
L. The ten percent handling fee on the value of commodities due the NMS for handling, storing
and shipping supplies to the district level is such an obstacle to a smooth and efficient
ordering process that it should be made a guaranteed payment and taken out of the ordering
approval process. Options to do this range from 1) RH securing guaranteed funding 2) donors
prepay this 10% when commodities are received by the NMS, 3) a guaranteed amount be
authorized by line item in the sector-wide planning budgets or 4) a guaranteed amount be
included in the health sector debt-relief budgets.
M. If provided with a clear delivery order from the MOH and payment for services, the NMS has
the facilities, transportation and human resources to deliver contraceptive and other medical
supplies to the District level in a timely and efficient manner.
N. Dispensed to user data from a previously conducted 200 site survey should be entered and
analyzed. This work could be coordinated by the DISH II project and be used in calculating
the 2001 CPT report.
O. FPLM to provide technical assistance for contraceptive procurement in procedures,
specifications and quality control.
P. USAID/Uganda should consider sending RH Division and other key officials for Arlington
logistics training ASAP to build a cadre of trained officials.
Q. FPLM should encourage and arrange Uganda participation in RLI regional logistics activities.
13
District and Health Unit Level
A. Expired stock and damaged materials should be collected and removed from health facilities
and district level storage areas.
B. Basic storage job aides should be developed, disseminated and personnel trained.
C. Procedures manual need to be developed for district and other level inventory control and
stock ordering. The process should include the following:
design workshop to achieve agreement on procedures and forms,
development of training manuals and on-the job training aids,
testing of training in DISH and other project areas,
inclusion of logistics training in other training packages,
training of both policy decision makers and operational cadre,
emphasis on issued to user data for decision making.
D. Use resources of DISH Project and other projects to advocate for, test and support
implementation of inventory and ordering capacity building.
E. Use Supply Chain Manager computer system for inventory control and ordering in DISH
projects as a pilot for eventual nationwide use.
F. Define role of sub-district health center in logistics activities. The consultant’s initial
recommendation would be to avoid stock storage at this level.
G. Include drug, vaccine, contraceptive and other medical supply ordering in any district level
guidelines, tools and training.
H. Consider integration of contraceptive and other commodities with quarterly distribution of
essential drug kits to reduce costs and improve delivery.
I. Design and institute a system to re-distribute commodities in oversupply.
J. Look for funds to install basic shelving in the district stores.
K. Train storekeepers in basic storekeeping management, including documented storehouse
procedures.
14
15
Situation
Uganda, a land-locked country in East Africa, has achieved marked economic growth for the last
five years due to sound macro economic policies, liberalization and privatization of the economy.
However, household incomes have remained low, resulting in poor health indicators (MoH/HSSP,
1999).
The population of Uganda is estimated at 21 million with a total fertility rate (TFR) of 6.9.
Compared to regional neighbors, Uganda suffers from a heavy burden of disease. 75% of life-
years lost to premature death are due to ten preventable diseases. 20.4% of these deaths are a
result of perinatal and maternal related condition (MOH/HSSP, 1999). Use of family planning is
low in the country, with only 7.8% of the married women using modern contraception, while
91.6% of the women reported knowing about contraception (UDHS, 1995). In addition, Uganda
also has the highest adolescent pregnancy rates in sub-Saharan Africa (DISH Evaluation Survey,
1997).
Continued availability of contraceptives is essential to contraceptive use. In the last two years,
repeated stockouts of contraceptives were registered at national, district and facility level.
Monitoring of the Couple Year Protection (CYP) provided by the public sector institutions has
shown a marked decrease during 1999, when condoms went out of stock all over the country for
more than six months and the injectable contraceptive showed similar trend at the end of the year.
Several logistics factors have been identified as the cause of countrywide stockouts. These
include:
• delays in-country procurement clearances due to tighter implementation of the importation
rules by the National Drug Authority (NDA);
• outstanding debt owned to National Medical Stores (NMS);
• donor dependent supply system which resulted in changes in product availability,
• restrictions on procurement and financial cuts faced by donors;
• decentralization of health services resulting in lack of information available at the central
level to plan for nationwide procurement.
United States Agency for International Development (USAID)-Uganda and the Ministry of
Health (MOH) recognized that availability of contraceptives was not only essential for achieving
program objectives, but also crucial for saving women’s lives from unwanted pregnancies. To
ensure adequate and timely supplies of contraceptives, the Mission and the MOH requested John
Snow Inc./Family Planning Logistics Management (FPLM/JSI) to conduct an assessment of the
reproductive health logistics system and provide operational recommendations.
16
Objectives:
The main objectives of the assessment were:
1. To assess the status and function of the logistics-based activities of key partners at all levels
of the Uganda supply chain for reproductive health supplies.
2. To identify main causes of recurrent stockouts of contraceptive supplies and identify areas
that need to be strengthened or streamlined in order to improve the flow of the products
through the system.
For the complete scope of work and other objectives of the consultancy covered (see appendix 1).
Methodology
The assessment was conducted as a joint collaboration between the Ministry of Health (MOH),
USAID/W, USAID-Uganda, Delivery of Improved Services Health (DISH) II and JSI/FPLM.
USAID/REDSO and USAID/Africa Bureau through the Regional Logistics Initiative provided
the financial support.
The assessment was based on a systems approach, using the logistics cycle as framework (see
appendix 2) to ensure a complete and systematic review of all logistics-based activities, at all
levels of the supply chain, from central level to the health facility. All public health product flows
currently existing to get the commodities to the customer were assessed.
The team used key informant interviews and review of the records at each level of the system to
gather the data. A final interview and observation schedule appears in (see appendix 3). Cross-
checking of the data reported by the different levels was done with the level above or below and
with as many people as possible.
The first week, the team interviewed stakeholders in Kampala. In the second week, a team of
USAID-Uganda staff, Ms. Betty Nabirumbi, DISH Logistics Officer, Mr. Muyingo Sowedi, two
FPLM staff, Mr. Steve Wilbur, Country Team Leader and Ms. Sangeeta Raja, Logistics Advisor
visited four districts in the eastern part of Uganda. The team, in consultation with USAID, MOH
and DISH, choose a purposive sample to visit. The eastern part of the country was chosen
because it was possible to cover more districts supported by a range of donors, was logistically
feasible in the time available to conduct the assessment and represented similar conditions to
other districts.
Reproductive health staff at the national MOH level were not able to join the team during the
field visit due to a heavy workload. However, Dr, Florence, Ebanyat, Assistant Commissioner,
RH Division provided a letter of introduction that the team could give to the DDHS of each of the
district. One of the members of the district health team (DHT) accompanied the team when
visiting the health facility within that district.
17
Table 1: Sites visited to assess the supply chain at the district and health facility level.
District Site visited
Donor Supporting the
District
Kamuli Kamuli District Office
Level III Clinic
USAID
Pallisa Pallisa District Health Office
Buseta Clinic
DfID/ UNFPA
Mbale
Mbale District Health Office
Budadiri Sub-District Clinic
Buwalasi Clinic
UNFPA Regional RH Program
Coordinator
DfiD
Iganga Iganga District Health Office
Muyuge Health Center
UNFPA
Kampala Kiswa Health Centre UNFPA, USAID
Quantitative indicators such as stockout rates, percentage stocked according plan, wastage rates
were not collected as part of this assessment since the DISH Project will be conducting a
quantitative survey to assess the drug supply situation at the health facility level in June and July
2000. FPLM consultants provided written suggestions to their survey.
This report by the consultants describes, in depth, the structure of the system, mode of operation,
relationship between the different divisions and levels and provides recommendations for
improving the logistics system.
Background
Ministry of Health Organization and Structure
Uganda administratively is organized into 45 districts, which is further divided into counties, sub-
counties, parishes, and villages. At each level, there is a local council, made up of politically
elected and administrative staff in charge of the area. In order to bring quality health services
closer to the community. Health Sub-districts are being created to cover a county. Any hospital,
(GOV or NGO) or a health centre within the county will be upgraded to Health Centre IV, will be
the referral unit for the HSD. The HSD will provide technical support and supervise all health
units within county. It will also be responsible for community outreach services.
At the central level, the Ministry of Health has several technical units including the RH Division
that provides guidance and policy support to the 45 districts.
18
Sector Wide Approach
To reduce the mortality and morbidity from the major causes of ill health, the MoH, other key
ministries and its development partners have developed a Health Sector Strategic Plan (HSSP).
The health sector reforms include decentralization to the 45 districts and sub-district level,
outlining a basic minimum package of health services to be delivered to the Ugandan population
through the districts and formulating policies, standards and guidelines for the delivery of health
services.
In support to the sector wide approach, some donors, mainly, Department for International
Development (DfID), Swedish International Development Agency (SIDA), Irish Aid and the
World Bank are preparing to support a common basket funding.
A major concern for family planning activities is the donor funds earmarked for purchase of
family planning commodities will now be placed in the basket funding, with uncertain results for
commodity purchasing. This must be tracked closely by the RH Division and the donors to ensure
that sufficient products will be available under the new approach.
The sector wide approach will start from July 1, 2000. As of this date, PHC conditional grants
are being allocated to the districts to implement the priority programs they have developed under
the MOH guidelines. However, there are also district based donor funded activities that provide
extra support to certain areas. The SWAP approach is designed to permit more equitable
distribution of resources, but both systems will co-exist for some time.
In view of the high maternal and child mortality rates, reduction of fertility through family
planning has been identified one of the objectives of the HSSP. However, there still a poor of
understanding at the national and sub-national level of the impact of population growth on
development and health. Many of the stakeholders interviewed felt that family planning received
a low priority by the key decision-makers.
Health Supply Chain Systems
Ugandans can access health commodities through various channels. These include buying from
private vendors of all types, MOH health facilities, social marketing programs and NGO operated
facilities.
Health supplies are brought into the countries by donors, church organizations, government of
Uganda and private companies. They usually arrive through two ports of entry, Mombassa for sea
freight and Entebbe for airfreight. Most suppliers use freight forwarders to assist in the clearance
of customs.
Prior to being allowed in the country, the supplies are inspected by the National Drug Authority
(NDA) and given a seal of approval for entry. Depending on the circumstance and the quantity,
the NDA can take one day to a month to inspect a consignment. The commodities are then stored
in the various warehouses before they are distributed through the different channels.
19
Lead times to get supplies into the country are dependent on the supplier’s procurement systems,
but can range from 2 months to 3 years. Unlike some countries, there is no procurement unit
within the MOH supply chain to coordinate the planning and procurement of supplies.
It has been shown in the private sector logistics that aligning the strategies of the various
suppliers within the supply chain has decreased the total cost, increases customer fulfillment rates
and increases the overall profitability of all the suppliers in the supply chain. In the case of the
Uganda, the strategies of all the suppliers (e.g. donors, NMS, districts, clinics) involved in the
public sector supply system, are not harmonized. This makes it difficult to create a smooth
logistics system that can result in a win-win situation for all the stakeholders.
There is therefore need for all the stakeholders in the supply chain to develop a harmonized
strategy that would ensure a win-win situation for all. Different individual objectives sometimes
work against common goals. The public health supply chain would benefit if all stakeholders
reviewed their objectives together and developed a harmonized strategy with shared performance
indicators. These indicators could include monitoring of total delivered cost, customer
satisfaction index etc.
Table 2: Impact on Supply Chain when Strategies are not harmonized
Supply chain
stakeholders
Strategies/Issues impacting
supply decisions
Result to supply chain
Donors
• Purchase the best product at
the lowest cost
• Funding available only through
a certain period
• Restrictions on procurement
• Bulk purchases, mean large
shipments which clog storage space
• Long-term planning not possible
• Overlapping products
NMS
• Provide services at a low cost
(break even)
• Pressure to Increase charges
• Decapitalization
• Reduce service
• Delay orders
District
• Ensure supplies are there
when customers needs them
• Local purchasing
• Increased transportation costs –
seek ways to get supplies released
from NMS
Health Facility
• Ensure supplies are there
when the customer needs
them
• Local purchasing
• Referring customers to other supply
chain (social marketing)
20
Figure 1: Supply chain for Public Health Commodities
Kfw
Italy
WB
USAID
DfiD
UNFPA
KfW
IPPF
DANIDA
GoU
Churches
IDA/WB UNICEF
Rotary Int’l
GoU
UNAIDS
UNICEF
TB FP ED STI Vaccines
Vitamin A
Anti Viral
Drugs
Port of Entry
Mombassa Entebbe
Freight Forwarders
NDA
FPAU MSI KPI/CSM NMS
(Entebbe)
NMS
(Kampala)
JMS RH
Office
UNEPI
Private Vendors
DISTRICTS
HEALTH FACILITIES
GoU and NGO
CUSTOMERS
Private Vendors
21
Logistics Systems for the Management of Public Health
Supplies
Essential drugs
Managed as a push system. The government of Uganda and DANIDA purchase essential drug
kits from the international market. In addition, the government purchases other required drugs
both locally and internationally in bulk. Once in country, the NMS packs them into kits and labels
them for each clinic. The amount per kit is determined periodically using morbidity and
demographic data. The kits are distributed quarterly to the districts, which in turn ensures that
they are directly delivered to the clinics as soon as they are received. Patient load and stockout
data is reported on a monthly basis to the central level. The NMS uses this data to review the
order quantities for each of the kits and make adjustments accordingly. The current max is set at 5
months and min at 2 months for both the districts and the clinics.
Contraceptives
Managed as a pull system. The health facilities order contraceptives monthly from the district
health office based on the last months’ consumption. The districts order their supplies every
quarter from the NMS. Due to management issues discussed in detail in the report, this system is
currently not fully operational. The health facilities reports dispensed to user data every month to
the district. The district in turn aggregates the data of all the clinics and reports to the planning
unit at MOH where the data is entered into a database. Like the essential drugs, the current max is
set at 5 month and min at 2 months both at the district and clinics. The national level max is at 12
and the min at 9 months.
Figure 2: The contraceptive logistics system
DONORS
DfID, UNFPA, USAID, WB, KFW
NMS
Districts (45)
Health Facilities (+1156)
CLIENTS
Planning
Unit
RH Unit
Key
Product Flow
Information
Flow
ACP
22
Uganda National Expanded Project on Immunization (UNEPI)
Logistically, UNEPI maintains a separate vertical procurement, storage and distribution system
from the national level, down to delivery at the SDP. Vaccine distribution requires maintenance
of a continuous cold-chain, which drives this extensive logistics system. The vaccines Tetanus
Toxoid are BCG, DPT, Polio, Measles and Tetanus. UNEPI also distributes Vitamin A capsules,
which were originally distributed as part of the National Immunization Day (NIDS.)
UNEPI maintains a well-equipped warehouse for vaccine storage on the grounds of the National
Medical Stores, but it operates independently. It has a fleet of three ten-ton trucks, which carry
only UNEPI supplies. There are four large refrigerated storage units, with temperature controls
and back-up generators, plus other storage space at the warehouses.
Forecasting is essentially done on a demographic basis, with targets to reach 80% of the children
in Uganda in the year 2000. Procurement is done through UNICEF, and supplies arrive regularly
on a quarterly basis. Because this has been an on-going coordination for many years, lead-time is
very short, documentation is routine and there are no problems with NDA or customs clearance.
Procurements are air freighted in, cleared from the airport to the UNEPI that day and put directly
into cold storage.
There is monthly delivery to each District, according to a delivery schedule. UNEPI does not
deliver to four districts for security reasons, so supplies are delivered to nearby districts and the
affected districts must pick up their commodities. All districts are in radio contact with the central
warehouse. Each district has a cold chain manager, who is the focal point for tracking
commodities. Propane cylinders for refrigerated units are delivered on a 2-bin, replacement
system and refrigerated units for repair are transported back by UNEPI trucks.
From the districts to the SDPs, supplies are both delivered and picked up. Most districts have a
motorcycle with a cold box for regular delivery to the health facilities. One-month supply is
supposed to be kept at the HU level. The district makes distribution decisions, theoretically based
on user data. Wastage is locally recorded and locally disposed.
Vaccine coverage has declined in recent years, but this is not related to logistic issues.
The consultant discussed with the UNEPI staff the question of logistics integration. With their
facilities within the NMS compound, separate trucks going to the same District Centers and
parallel staffing, this is an obvious question. There was recognition of the pressure to integrate
systems and a sense that this will eventually happen, but an understanding that this would be
some time in the medium to far future. With the special requirements for cold-chain maintenance,
strong donor financial support and the uncertainties of other logistics systems, it is not likely that
this vertical system will be dismantled anytime soon.
Integration Possibilities
As mentioned above, there are several parallel logistics systems operating. These include
Essential Drug Kits; STI kits and drugs TB/Leprosy drugs, family planning commodities and
vaccines.
The key to this possible integration is the Essential Drug kit delivery system, which distributes
these kits every three months on a regular schedule. Since the ED kit system is unlikely to be
23
changed anytime soon, other delivery systems can piggyback on this system. With STI drug
procurement moving from separate project status to inclusion in the Sector Wide Approach
system, procurement and a coordinated delivery will likely be absorbed into the NMS system. TB
and Leprosy drugs are now delivered by NMS to TB regional centers, which then distribute them
to district centers. This system does not need to be maintained separately and can certainly be
integrated at the NMS, with delivery directly to the districts.
The original objective for family planning commodities was that they be distributed with the
essential drug kits. With shortages requiring the districts to scramble for supplies, MOH inability
to pay for the NMS 10% distribution fees to the NMS throwing distribution off schedule and
inefficient ordering from the District level, this possible system has fallen apart. If the 10%
handling fee issue can be resolved, it will be possible to organize district ordering to fit with a
three monthly delivery schedule for essential drug kits. Since the farthest point for delivery to the
Districts is only 9 hours, emergency delivery off schedule is also practical. Individual donors will
still do procurement, but storage once received in country, and delivery from the Center to the
Districts, can be accomplished by the NMS system.
Vaccines is not likely be integrated anytime soon due to special handling requirements.
Tanzania has demonstrated an effective integration of essential drugs, vaccines and
contraceptives. The Medical Stores Department does some procurement, receives all supplies and
delivers them to the district centers. They maintain the cold chain for vaccines to the district level.
This system seems to be working effectively. Family planning supplies were the last to be
integrated. FPLM assisted in this integration, a process that took almost two years.
The MSD in Tanzania is sufficiently efficient that socially marketed contraceptives are stored by
them and distributed to provincial (Regional) warehouses, where social marketing staff collects
them for distribution to wholesale and retail outlets. MSD are paid for this service.
Further down the delivery chain, more supplies and systems are effectively integrated. Storage
areas are shared, the staff controlling distribution is the same, and facilities at the SDP level are
often one cupboard containing all medicines and supplies.
Product Selection
Essential drugs are selected from the Uganda essential drug list and those recommended in the
standard treatment guidelines. The program only purchases generic over brand in order to get a
better price for the drugs.
As outlined in the RH policy, a wide range of contraceptives, both long and short-term methods
are currently available through the public and private sector. The method mix includes
injectables, oral contraceptives, and barrier methods.
There seems to be a dramatic increase in the use of Depo Provera and a decrease in the use of
IUD and VFTs. Majority of the condoms are in the system are for the prevention of STI and HIV.
The STI project and AIDS Control Programme (ACP) logistically manage the condoms.
24
Contraceptives are usually selected through a joint process between the RH unit and donor.
However, it has been difficult for the RH unit to keep the balance of ensuring a wide range of
supplies of the same type of brands partly because of the donor restrictions of what products they
can supply. As a result, the system has many brands. UNFPA has flexibility to procure various
types of brands of contraceptives, while USAID is limited to purchase only American-
manufactured brands.
In many of the cases, the brands are of the same active chemical composition. This can be
positive in that women can substitute brand of the same active chemical composition in case the
brand of choice is not available. On the negative side, brands of the same chemical composition
do not increase women’s choice, can create confusion for the clients and are very difficult to
manage logistically.
The team found that Family Planning Association of Uganda (FPAU) had the most number of
brands in their system, followed by the MOH.
The result of a wide range of contraceptive brands in the system has been a result of donor
dependency to provide the contraceptives and inability to secure long term donor commitment for
the provision of contraceptives.
25
Table 3: Methods, brands available at the MOH, social marketing program and FPAU
Method Mix Contraceptive Brand Supplier Recipient Code
No Logo USAID FPAU
Protector USAID CMS
Protector CMS FPAU
Engabu IDA/WB MOH
LifeGuard KfW MSI
LifeGuard MSI FPAU
Condom
Depo Provera DfiD MOH d’’’1
USAID CSM, FPAU d’’’1
Progesterone
Injectables
Norplant USAID MOH h’’’’1 Implants
Copper T 380 USAID
DfiD
MOH, FPAU
MOH
IUD
Lo Femenal USAID MOH h4
Lo Femenal MOH FPAU h4
Duofem (Pillplan) USAID CSM h4
Duofem (Pillplan) CSM FPAU h4
Microgynon UNFPA MOH h4
Microgynon MOH FPAU h4
Eugynon MOH h3
Neogynon IPPF FPAU h1
Combined
Pills
Ovrette USAID MOH h’’1
Ovrette MOH FPAU h’’1
Microval UNFPA MOH h’’2
Microval MOH FPAU h’’2
Progesterone
-only Pills
Conceptrol Foaming Tablet USAID MOH
Conceptrol Foaming Tablet MOH FPAU
Delfoam IPPF FPAU
Cotexmax Jelly IPPF FPAU
Neo-Sampoon UNFPA MOH
VFT
Barrier Diaphragm IPPF FPAU
Note: IPPF stopped providing Noristerat as it was not registered in the country.
Note: The code is taken from the Directory of Hormonal Contraceptives, 1996. Each brand of
contraceptives is given a code, which indicates its composition or formula. For example a women
using microgynon could equally use Lo-Femenal, since both products have the same amount of
active estrogen and progesterone.
26
Procurement
Essential drug kits are procured by DANIDA and provided to the government of Uganda. In
addition, the government also purchases some drugs through international tender procurement. As
there is no procurement unit within the Ministry of Health, the procurement is managed by the
NMS. Tendering systems are in place. Under the sector-wide approach there are several scenarios
being discussed for the management of procurement. These include establishing a procurement
unit, placing a procurement officer under each technical unit and or keeping the status quo.
UNICEF and government of Uganda purchase vaccines. These vaccines are procured through the
UNIPAC catalogue.
The donors procure contraceptives. Since each donor has a different procurement cycle, projected
forecasts are needed at different times of the year. Forecasts for the coming year are usually done
between July – December. The specific donor does procurement, shipping and clearing, with
delivery to the NMS or social marketing systems directly.
Forecasting
Projections for essential drugs are done using morbidity and demographic data. Vaccines are
projected using demographic data and contraceptives are projected using demographic data,
issues data from the national level and surveys that are available at the time. USAID/Uganda has
provided technical assistance through a consultant to determine the forecasts.
Due to lack of data, it is very difficult to know the current stock in the country at the different
levels or consumption rates. This makes accurate forecasting difficult.
27
Table 4 : Contraceptive Stock Situation based at the NMS as of May 16, 2000
MAX: 12 MoS MIN: 9 MoS
Months of Stock Available at the National Level
Contraceptives Based on 1999 CPT
Data
Based on Spectrum
Data
Based on NMS Issues
Data
MOS MOS MOS
Condom 43 55
FP
HIV/STI
Pill 9
Lo-Femenal 17 17
Microgynon 59 378
Microval 20 12
Ovrette 35 29
Implants
Norplant 33 83
Injectable
Depo Provera 16 13 224
VFT 11
Conceptrol 25 24
IUD 6 5
Table 5: Consumption Projections by Different Sources
CPT Projections for 1999 Contraceptives
MOH SM Total
Based on
Spectrum Data
Condom 25,000,000 20,400,000 45,400,000 19,651,045
FP 2,000,000 5,489,662
HIV/STI 23,000,000 14,161,383
Pill 1,625,000 3,291,618
Lo-Femenal 325,000 830,000
Microgynon 325,000
Microval 25,000
Ovrette 120,000
Implants 6,000 6,000 2,398
Norplant
Injectable 700,000 175,000 875,000 836,276
Depo Provera
VFT 200,000 220,000 440,000 436,624
Conceptrol
IUD 8,000 8,000 9,306
SM = Social Marketing
MOH = Ministry of Health
28
Donor Coordination
A series of donor meetings are held to seek donor commitment for the purchase of the projected
quantities for contraceptives for the upcoming years. This process is one of the strengths of the
system. It ensures that donors at least meet once a year and provide commitment to the purchase
of contraceptives and meeting the contraceptive requirement gap. The main donors that support
the procurement of contraceptives are USAID, DfID, KfW and UNFPA. USAID and KfW mainly
provide contraceptives to the social-marketing programs, while UNFPA and DfID provide to the
MOH.
There is close collaboration among the donors and the RH unit, which has allowed them to make
adjustments in product supply as quickly as possible. In the last year, UNFPA had a cut in
funding and was not able to meet its procurement obligations of pills. DfID managed to bring
emergency shipments, which averted a national stockout.
Drug Regulation and Importation
The National Drug Authority (NDA) was established in 1993 by the act of parliament. The main
mandate of the organization is to ensure that drugs brought into the country are of a good quality.
The NDA has regulatory authority over all drugs and medical supplies in Uganda, including all
contraceptive products. Their approval is necessary for the importation of all contraceptive
products. They follow World Health Organization (WHO) guidelines for contraceptive
specifications. All imported products must be registered with the NDA. In addition, all packaging
and labeling must be registered with them. When manufacturing or packing changes are made,
these changes must be registered.
NDA also has the authority to conduct quality control tests on all products. This is done both in
Uganda and externally, depending on need.
In early to mid-1999, several batches of condoms to be imported failed initial quality control
testing. Extensive quality re-testing, and destruction of some condom batches, contributed to a
serious stockout of condoms in the later half of 1999.
In addition, NDA undertook extensive review of all labeling and packaging for all importers of
condoms – the STI Project, CSM and MSI. Detailed compliance with WHO specification
guidelines was required for all parties and some packaging and labeling changes were needed.
These packaging, labeling and quality control issues raised by the NDA seem to have been sorted
out for all parties importing condoms at the moment. This of course must be tracked closely by
the Stakeholders group, since any delay in importation or acceptability of condom requirements
for Uganda will effect all parties and total supplies throughout the country.
In a similar manner, the NDA has closely monitored importation of all other contraceptive
products. Again, all issues seem to have been worked out, but this must be closely monitored.
As part of the program to address and rectify any questions on contraceptive quality and labeling
from US sources, USAID/Uganda asked Ms. Bonita Blackburn, USAID Contraceptive
Procurement Specialist to accompany the FPLM logistics assessment team. The specialist met
with the National Drug Authority to answer any questions about US products
29
Product Review with NDA
On May 3, 2000, the team accompanied by Florence Ebanyat, Assistant Commissioner for
Reproductive Heath, MOH, met with Dr. John Lule, Acting Executive Secretary, Francis Otim,
Drug Assessment and Registration and Gabriel Kaddu, Senior Inspector of Drugs at the National
Drug Authority (NDA). A review of the status of the registration of USAID contraceptives
was the topic of our meeting.
The team gave an overview of the their objectives followed by a brief description of the provision
of USAID contraceptive to the family planning and HIV/AIDS prevention activities in Uganda.
The team reviewed with the NDA each USAID contraceptive product that is imported into
Uganda beginning with the 52mm non-colored Blue/Gold condoms (52NG).
52NG condoms: USAID condoms meet all the WHO standards and all the WHO specifications
with the exception of the labeling. The WHO standards are developed by the International
Organization for Standardization (ISO) and are designed to establish a minimum level of quality
for products (e.g. condoms) that are imported and sold, within a particular country or region. The
WHO specifications are a buyer's requirement and simply sets package integrity requirements for
condoms because they have to withstand tropical or other conditions of storage and distribution.
The WHO specification requires that all condom foil sachets be labeled with both the
manufacture/expiry dates and the lot numbers. USAID condoms only have the expiry date and
the lot numbers on the foil sachets. USAID does not have the manufacture date on the their
condoms. It is not part of the design factor in our contract.
USAID ships condoms to 60 countries worldwide. In l999, USAID shipped approximately
94,500,000 pieces. In order to do meet this volume, USAID has to award large, multi-year
contracts. These multi-year contracts allow manufacturers to schedule continuous production and
pass substantial savings along to the Government. In l998, USAID negotiated a contract with a
U.S. manufacturer, London International Group (LIG), for a period of three years. This contract
outlined the USAID specifications required from the manufacturer in order to provide the
condoms. This contract specifies that the individually packaged condoms (foil sachets) are to be
marked with the manufacturer's logo and/or name, production location, "Made in USA", the date
of expiry and the manufacture's lot number. Bonita continued to explain that no other country
that receives USAID condoms requires both the manufacture and expiry dates on the foil sachet.
The NDA pointed that that it is their responsibility to the people of Uganda to ensure good quality
condoms. Their concerns centered on clients receiving expired product. The team pointed out to
the NDA that the USAID condom is a good quality product and that is what they wanted for
disease prevention activities. There can be exceptions to the labeling but no exception to the
performance or manufacturing requirements of the condom. USAID condoms meet both ISO and
ASTM standards. In addition, USAID condoms are tested by an independent laboratory, Family
Health International (FHI), and USAID can provide quality assurance documents for each
shipment by lot number. In addition to testing, USAID asks FHI to retain samples of each lot for
future testing if there is a quality assurance problem within country.
The Commercial Markets Strategies Project (CMS) in conjunction with PSI and Kampala
Pharmaceutical Industries (KPI), overpacks and distributes USAID 52NG condoms as "Protector"
condoms. These condoms are sold for a small cost recovery fee in private sector clinics
30
countrywide. The local overpacking done by KPI includes all the information required by the
NDA for the importation and distribution of the USAID condoms. In addition, USAID's
inner cartons of 100 condoms also includes all the information (manufacturer/expiry dates, lot
numbers, manufacturer's address, etc) that is required by NDA.
After much discussion, the NDA was willing to agree to the importation of USAID condoms for
the CSM program since the local packaging did include all the information required by the NDA
in accordance with the WHO guidelines.
Since the USAID condoms for the public sector program (52mm non-colored, no-logo condoms)
will not be overpacked with the required NDA labeling, any request by the MOH for USAID-
supplied condoms will require a waiver from the NDA for this specific product.
It is important at this time to point out two significant questions asked by the NDA:
(l) Does the U.S. domestic market use the same manufacturer for condoms? The team
explains that LIG does manufacture condoms for sale in the U.S. domestic market. In
addition, we explained that LIG is a worldwide manufacturer of condoms and that their
Durex brand of condom is a gold star condom, known worldwide.
(2) What is the relationship of CMS with USAID? We explained that CMS is a centrally-
funded project that is funded by USAID to increase contraceptive supply through private
sector partners and commercials strategies. CMS also covers underserved, rural and
urban areas and populations and works to improve governments' ability to rationalize
resources and collaborate with the commercial sector. We pointed out that USAID
determines the specifications for the condoms used in the CMS social marketing
program.
Duofem - The NDA issue with the low-dose oral contraceptive pill, Dufoem, was that it was
registered as Lo-Femenal not Duofem. Although Lo-Femenal and Duofem are the same chemical
formulation, NDA requires separate registrations. The distinction in the names of these products
identifies them either as public sector product or a CMS product. Lo-Femenal is the
public sector product while Duofem is the CMS product. Bonita agreed to provide the NDA with
a Certificate of Free Sale and a registration dossier for Duofem.
Again, NDA was willing to accept this product based on the fact that it would be overpacked as
PilPlan and that it would meet all the WHO specifications.
At this time, we agreed that either USAID or CMS would notify NDA immediately if any
changes in product or packaging occurred in the future.
Depo-Provera: No problems. Registration approved and on file. Product can be imported.
Norplant: Same as Depo. Registration approved and on file.
Summary: All parties agreed that the importation of USAID contraceptives for the CMS and
MOH public sector programs is acceptable to the NDA, with the exception of no-logo condoms
for public sector distribution, which would require a specific waiver.
31
Distribution
The table below identifies the various organizations involved in the distribution activities in the
various programs
Program Distribution Activities
Procurement Warehousing Transportation
Public Sector NMS/Donors NMS/district stores NMS/Recipient
CMS USAID KPI Agents
MSI KfW KPI Agents
JMS JMS JMS Recipient
FPAU FPAU Stores Recipient
Warehousing
National Medical Stores
History, role and responsibilities
The National Medical Stores was created by an Act of Parliament in 1993 and replaced the
Central Medical Stores. The purpose was established as the procurement, storage and distribution
of drugs, contraceptive products and medical supplies. It is a parastatal organization designed to
serve both commercial and public sector service components.
There is extensive documentation, which describes the history, accomplishments and problems of
the NMS, which were reviewed and are referenced in the annex of this document. Here we will
document those facets that are most pertinent to family planning logistics at the present time.
The NMS presently carries 750 products, through computerized inventory. They have a 9 billion
Ugsh turnover per year. (about 6 million US dollars). They provide limited credit for drugs to the
district level. They distribute Essential Drug kits, both STI drug Kits and STI individual drugs,
TB and leprosy drugs to regional TB centers, and they distribute family planning commodities.
They do not distribute or are not involved in the UNEPI vaccine distribution program, though that
program is physically within the NMS compound in Entebbe.
NMS has no role in the procurement of contraceptive products. The purchasing, NDA approval
and customs clearance of these donor-supplied products is handled exclusively by each donor and
RH Division.
The NMS role is to receive the supplies, warehouse and store the products safely and to ship the
products to the district level, when told to do so by the MOH. It is very important to understand
that the NMS has a very limited role. They are essentially a storage and delivery company, with
no role in ordering contraceptives, approving district level orders or making stock requirement
decisions. They receive the products once cleared, store them and delivery them when told where
and when.
32
Facilities
The NMS has a large compound in Entebbe. There are four major warehouses, with racked
storage areas and 2 forklifts capable of moving inventory from any spot. The facilities are well
designed and are well maintained. There is separate storage space for inflammable items,
corrosives, narcotics, and refrigerated items. Receiving and shipping bays are clearly demarcated
and there are kit packing areas if needed. Temperature is reasonably well maintained. While
improvements are possible, the facilities are very good and are well maintained.
There are four trucks available, with four detachable wagons to increase carrying space. There are
5 truck routes set up for delivery. FPLM through the Regional Logistics Initiative has worked
with NMS to implement a computerized transport management system (TMS) to improve the
space utilization and scheduling of these existing trucks. The trucks are aging, but sufficient.
NMS has just build a new warehouse, which will effectively contain only an expected shipment
of STI Project supplies. Condoms will take up a majority of the space.
It is the consultants’ opinion that NMS has the physical facilities, the vehicles and the trained
people to effectively provide storage and delivery service to its district level clients if all proper
documentation where completed in a timely manner. This however is often not the case and
circumstances beyond NMS control often preclude efficient delivery of the product to the field.
For Family Planning products, these circumstances beyond NMS control include:
- inefficient procurement leading to product stockouts
- incorrect clearance and registration leading to clearance delays
- delayed ordering from the district level
- delayed processing of instructions to ship from the RH unit of the MOH
- non-payment of the required 10% handling costs or non receipt of the certification
that MOH funds are available for this payment
From field visits, the NMS is perceived as providing a good service on schedule for essential drug
kit delivery to the district level. When asked if they would use the NMS service if they had other
options, the general response was that they would, since the quality of the drugs was perceived to
be high, with lowered risk of being cheated.
With major stockouts in FP products in 1999, and few other options, this question was not asked
of contraceptive products supplied by the NMS.
It was also noted that NMS has recently established a Kampala branch of the NMS for local sales
and supply within the Kampala area. The existence of a price comparison center has seemed to
help stabilize drug prices in the capital area.
Management Issues
There are several management and organizational issues that jeopardize the on-going work of the
National Medical Stores. As noted, these are fully documented elsewhere, but are briefly
mentioned here because of the potential impact on NMS services in the medium and long-term.
33
One is that there has been no Manager for the NMS for several years. The present management
team is in an acting capacity, which limits the ability to make key long-term decisions and does
not allow for guidance and necessary planning.
There currently is, and has been for some time, the idea that the NMS would be privatized. This
has resulted in current employees operating without employment contracts, and uncertainty
resulting in low employee moral.
The NMS is regularly effected by scandals in drug procurement. Two officials were arrested
during this consultancy visit. This of course effects public perception of the role and value of the
NMS.
In addition to drug procurement losses, the NMS is also in debt, rumored to be in the 4 million-
dollar range. Substantial sums are owed by other branches of the government, and are difficult to
collect. This is partially the result of the dual nature of the NMS, which is to be an efficient
business, but also to provide drugs and service to the people of Uganda. This debt leads to an
increasing decapitalization of operating funds.
It is not yet clear how these issues will be resolved. Privatization is being promoted, and has been
decided philosophically but with 51% of the company to remain in Government hands and a
substantial debt, this may not happen soon. Discussions are on going, but the NMS is in Class II
(second priority) for privatization efforts by the government commission.
Ordering
Ordering and Delivery processes from the National Medical
Stores
The process depends on which type of product is being distributed.
Essential Drug kits, are distributed based on a push system with a pre-calculated number of drug
kits labeled for a specific health unit. These are distributed every three months on a set schedule
and are sent to the district health center for re-distribution, as a closed kit. The 10% handling fee
is paid by the Danida Project, which is then reimbursed from government funds for this
counterpart commitment.
STI kits, the situation is a bit more confusing. Most STI drugs are contained in a kit form, and the
number of kits is pre-set. Ordering is not on a set schedule and kits are sent out usually on a
different schedule from the essential drug kits. The 10% handling fee is supposed to be paid now
by the STI Project, but payment has not been made at all. The drug kits however are being
distributed without this fee payment because of the critical nature of the need for these supplies in
the field.
In addition to drug kits, some drugs are ordered, collected and sent as individual pieces. The
ordering is done theoretically based on client use at the district level, but this is not quite clear.
These drugs are distributed at the same time as the STI drug kits.
34
TB and leprosy drugs are distributed on a push system. The TB officer at the district level orders
the supplies. Supplies are shipped by the NMS after proper technical approvals. These drugs are
then shipped to regional TB centers, and then the district level collects them. While this uses
NMS trucks, it is another separate logistics system.
In the field visit, to the districts, Pallisa and Mbale complained that the regional center for the
eastern region is in Kumi. This has added additional cost in terms of transportation and time for
the district to collect their supplies from the regional centers.
Contraceptive products are based on pull system. The ordering is supposedly done by the
calculation of issues to users, but in practice it seems to be a variety of methods using issue data,
consumption figures, replacement plus 30%, etc. This will be addressed in more detail in a
section on district level training needs. Most of the health facilities pick up supplies after they
have stocked out completely.
Once the order is completed from the district level, it is sent to the RH unit at the MOH. They
review and approve it and send it to the NMS. NMS confirms that order can be supplied and
calculates the 10% distribution fee and send to MOH to process an LPO. The LPO is returned
before delivery is made by NMS. In normal circumstances, this process would run smoothly if
the RH unit received funding allocation from the Ministry of Finance (MoF) to cover these
charges. This year, the government did not achieve the expected revenues. As a result, the MoF
has asked each of the ministries to cut their planned activities in order to be within the reduced
allocated budget.
The RH Division has requested the 10% storage and distribution funds but has not received any
allocation from the Finance Department through the MOH for the last two years. Since the NMS
is also trying to maintain a viable business by charging for their delivery services, they require
payment of this 10% handling fee. With the RH Unit having no approved funds to pay NMS for
this handling fee, this leads to periodic crisis. In the last year, the NMS stopped shipment of
contraceptive products to the field due to non-payment. To get partial payment made, the RH
Unit has had to seek approval from the Permanent Secretary to re-allocate funds for the Ministry
of Health to release.
Now, a guarantee that funds will be paid by the MOH is often required before commodities will
be shipped to the districts. This approval for the handling charge on contraceptives is often
delayed because funds are not readily available.
The NMS can then ship the contraceptive order to the district either with the regularly scheduled
essential drug kit shipment or can ship as soon as possible with other shipments going to the
appropriate district.
The other alternative is for the district to go directly to Entebbe to collect contraceptive products.
In a real local-level effort to speed up the process, some districts will come into Kampala and
Entebbe to speed up the contraceptive procurement. Usually this is done in connection with some
other capital city visit, but it demonstrates a genuine effort to provide needed services to the local
clients.
In this process, the districts must go first to the RH for order approval, then try to get the financial
clearance for the 10% handling charge. It is not often possible to do these things on one visit.
Then they must return to pick up the goods at the NMS warehouse in Entebbe
35
The RH unit has pursued several options to solve the problem of delay in product collection due
to the 10% handling fee requirement. This includes looking at the option of renting a warehouse
of storing RH supplies which was found to be too expensive to storing small amounts of supplies
in the offices at the MOH.
With severe stockouts of products last year, we have seen dedication on the part of the district to
try and acquire needed contraceptive supplies, often at the expense of other district priorities.
Ten Percent Handling Charge
As a private business handling medical supply distribution, the NMS is supposed to be recovering
its handling, processing and distribution costs. It has been decided that a 10% handling charge
would be assessed on the total value of the goods stored and delivered. This is to provide for the
operational costs of the NMS.
This is certainly a legitimate cost, and in fact is probably insufficient for the real handling costs.
NMS estimates that their actual handling costs are 22%. FPLM estimates a 10-15% logistics costs
on the total value are needed for commodity delivery to the district level.
For essential drugs, as mentioned above, this 10% is paid by the MOH as counterpart funds for
the DANIDA support to the essential drug kits (plus 50% of the actual cost of the drugs). This
however is paid immediately by DANIDA to the NMS, and funds are then reimbursed from the
government to DANIDA. Drug requirements however have highest priority, and the DANIDA
project has some clout to insure that this amount is indeed contributed.
For STI drugs, the agreement was that the STI Project would pay that 10% handling charge.
However, this has never been paid to the NMS, with large amounts due. Crown Agents estimated
that the NMS is loosing significant funds in supporting this program. The drugs however are still
being delivered by the NMS.
For contraceptive products, the 10% is paid by some donors and not by some other donors. DFID
does pay this amount. UNFPA and USAID had reached agreement with the Government of
Uganda that this 10% handling cost due to the NMS would be the government counterpart funds
for the contraceptive commodities donated.
This is a logical approach in principal. However, in practice, nonpayment of the 10% is causing
extensive delays in product release, occasional non-delivery of products by the NMS and
complicating the ordering and delivery system to the point that products are being wasted and
stockouts reported at the facility level.
With reduced government revenues, competing priorities and bureaucratic inefficiencies, this
money is usually not paid or is in severe arrears. At the moment, NMS has written the RH unit
saying that the MOH presently owes 198 million shillings for logistics handling costs for
distributed MCH supplies (Approximately $130,000 US dollars.) and threatening non-delivery of
contraceptive products unless the debt is at least partially paid. It was estimated that 75% of this
debt is from UNFPA non-contraceptive supplies.
As a business, NMS should certainly expect to be paid for the service they provide. However, the
reality is that the contraceptive supplies are delayed or not delivered due to this debt owed by the
36
MOH to the NMS. For the period Oct - Dec in 1999, the NMS refused to and didn’t deliver any
contraceptive supplies to the districts.
This even lead to the situation where the RH unit didn’t put contraceptive supplies into the NMS
warehouse for fear that they could not get them released later. So they stored them in RH offices
and distributed them directly to districts that had to come to Kampala to collect these supplies.
This is mentioned only to underline the severe contortions to the logistics system that the
government inability to pay the 10% handling charge is causing. It requires a “Certification of
Availability of Funds” be completed by the MOH to be given to the NMS as part of the product
release cycle to the districts. This tells the NMS that the MOH intends to pay.
This piece of paper is carried back and forth between the NMS and the RH unit, and within
several offices of the MOH itself. If there is a question that the MOH cannot pay, then higher
approval is required.
The handling charge issue adds between 3 weeks and 3 months to the time required to process a
district level order.
From a logistics standpoint, the inability of the Government of Uganda to pay this logistics
handling cost to the NMS creates a total distortion of the logistics system. It lengthens the lead
time to acquire products, it means that district level deliveries miss scheduled transportation and
must wait for another cycle and it means that products are not delivered in a timely manner,
leading to wastage of the product. In short, it creates an unworkable situation.
There are several options in dealing with this 10% handling fee, from immediate to medium term
to long term. For the immediate, it will be important to track the approval or lack thereof for the
272 million Uganda Shilling request for this handling fee made from the RH Unit through the
July 2000 to June 2001 MOH budget submission to the Ministry of Finance. The consultants met
with the appropriate officials at the MOF, and approval is dependant both on government funds
available, plus prioritization by the MOH. The donor organizations can also support this request
as part of MOF allocations connected with each donor. This needs to be tracked closely within
the next two months.
Even if funds are completely allocated at the 272 million level, there is an existing debt of 198
million, leaving little for the coming year costs. And it is likely with Uganda budget shortfalls,
that any allocation would be small.
The medium term is to have the donors cover the 10% handling fee for contraceptive products
supplied by them. DFID is already made this provision and is paying the 10% fee. USAID is
prepared to consider the possibility. UNFPA is prepared to review the need for this 10% fee and
will be conducting an operational review this summer, so the timing for a decision is correct.
NMS can track and bill for these costs per individual donor.
For the long term, funds could be included in the SWAP program, or even in the Debt Relief
program, so that the allocations are guaranteed, but within government budgets. Since many of
these systems are presently evolving, this may take some time and effort to get this allocation
included in these other government payment structures.
37
All parties would even benefit from a 10% reduction in contraceptive purchases by each donor, if
that fund could be used for the 10% handling costs. It would save time, wasted product and
improve service.
As a perspective, in Tanzania, USAID and UNFPA split 50-50 the total storage and distribution
costs for all contraceptive products. This agreement was started in July last year, seems to be
working well, and was brokered by FPLM. This 50-50 is certainly more than the 10% handling
costs requested here.
If it is not possible for the various donors to pay this charge to the NMS in advance when the
product is delivered to their warehouses, then another option might be to have SWAP funds
earmarked from the donor basket to cover this 10% handling fee. The end result would be
improved public sector services.
The RH unit of the MOH has already endorsed this idea. They see no advantage to having to
track down signatories for almost every shipment and would like this obligation to be removed. It
would then even be possible to have requests go direct to the NMS and be filled immediately if
they fell within already approved limits for each district. Elimination of this handling cost from
the RH responsibilities would improve the system enormously. In addition it would free up the
RH staff already over-extended to be able to focus to technical issues of reproductive health.
Inventory Control at the NMS
The NMS has installed a very efficient inventory control and warehousing system, which covers
all products. Shipment lots are tracked and stored by random bins, with computerized printouts
for picking supplies for shipment.
They can provide inventory tracking by supply source, meaning that donor-donated supplies can
be tracked separately. An accounting for the status of donor supplies can be provided within a
few minutes.
Using this same system, the NMS can provide up-to-the-day stock status for family planning
supplies at the request of the Reproductive Health Unit. This information would be very useful
for tracking adjustments needed to supply requests. The consultants would recommend that stock
status information at the NMS warehouses would be a subject for review at the proposed
stakeholders meetings every four months.
The consultants conducted a physical inventory count of all contraceptive products except
condoms in storage at the NMS on May 16, 2000. The NMS staff were particularly helpful in
accomplishing this count. We found that the physical count matched the computer generated
stock list with 100% accuracy in all items. We wanted to highlight this fact to demonstrate that, at
least on this day, NMS inventory control records were up to date and completely accurate.
Table 6: Results of a Physical Count of Contraceptives as of May 16, 2000
Contraceptives Physical Count Record Difference
Conceptrol 265,923 265,923 0
LoFemenal 85,600 85,600 0
Microval 41,596 41,596 0
Ovrette 6 6 0
Depo Provera 9000 9000 0
38
Expired Products handling at the NMS level
There are extensive amounts of expired contraceptive and drug supplies in storage at the NMS.
These expired products are carefully separated and stored away from the “active” supplies, but
the volume is increasing.
There seems to be no present way to dispose of these expired products. In addition to the usual
government regulations concerning expired materials and donor specific disposal requirements,
there are extensive environment regulations that combine to effectively prohibit the disposal of
these products. There appears to be no incinerator in country, which can handle the volume
needed, the high temperature requirements and the pollution control regulations. NMS has made
several proposal to construct such an incinerator but to date have not received the funding
necessary.
Until a high volume, environmentally correct incinerator can be built, contraceptive and drug
supplies will continue to collect at the NMS. At some stage, this problem will need to be
addressed.
Joint Medical Stores
The Joint Medical Stores was set up by the Catholic and Protestant church organization of
Uganda in 1979. The main purpose of the Joint Medical Stores is to deliver high quality
medicines at an affordable price. They currently procure essential drugs, medical supplies and
equipment for the 400+ health clinics and hospitals managed by the NGOs. The JMS mainly
procures through the international market, clears the supplies and stores them. Due to fewer
procurement regulations, JMS is able to have supplies delivered in Uganda ready for distribution
within 3 – 4 months. This enables the JMS to hold fewer inventories, decreasing the warehouse
space requirements and capital tied in inventory.
In the past, the JMS provided supplies on credit; however, this resulted in a major debt being
owed to the stores. As a result, the system operates on a cash and carry system. Credit is only
provided to credit-worthy facilities. The stores inventory turnover is over 4.5 million dollars per
year and estimates that it serves 30 - 50% of the overall essential drug market of Uganda. Some
of the NGO health facilities prefer to receive the supplies in kits, partly because it is easier to
manage and are based in remote districts with limited transportation. The JMS facilitates this by
working with the NMS to purchase the kits and ensuring that the kits are provided through the
NMS distribution system.
At this point, the JMS does not carry contraceptives. However, many of the facilities would like
one-stop shopping, whereby they can collect all their supplies from one point. Orders are
accepted by email, fax or hand delivery of the order forms and can be filled within 10 minutes to
two hours depending on the order quantity.
Transportation
The NMS currently has sufficient vehicles to provide for the delivery of all supplies down to the
District level. There are four Ten-ton trucks, with detachable wagons and 3 smaller trucks. This
fleet is aging, but still functional.
39
These vehicles operate on a regular schedule for delivery of Essential drug Kits every three
months, and also an as-needed delivery to the District centers. Effectively this means they visit
every District Center approximately once a month.
FPLM, through the Regional Logistics Initiative (RLI) has worked closely with the NMS to
install a computerized Transport Management System (TMS) which predicts vehicle routes, truck
loading, vehicle maintenance and fuel and repair costs. This system has been in operation for
several years and seems to be working quite effectively. This is an adaptation of a similar system
used in Kenya.
Logistics Management Information System
At the central level, there are various technical units that are responsible for a specific health
program. These include the Reproductive Health unit, Child Health Unit, STI/HIV/AIDS unit and
so on. Each of these units has reporting requirements and data they need to make national
decisions. The Health Management Information System under the planning unit of the MOH has
developed a set of forms that can be used for local level management and forms that is used for
reporting essential data for decision-making to the central level. Since 1996, the health facilities
throughout the country have been using these forms. A HMIS manual that provides information
on how to feel the data is available at the district level and can be obtained from the planning unit
at the MOH.
In some of the countries where FPLM has worked, the experience has been that the HMIS usually
is focused on gathering the epidemiology data and not the management data, especially logistics
data. This fortunately is not the case of Uganda. There are a set of logistics forms that allow one
to record all the essential data items (stock on hand, losses and adjustments and consumption) in
order to manage a logistics system for each level. However, these data are recorded at different
places but are not brought together to make logistics decisions such as determining order
quantities. The HMIS manual provides instruction on how to fill out the various forms and how to
use the data. However, in the field visit, the team found little evidence that the data was being
used at the local level for making logistics decisions.
Dispensed-to-user data is reported to the central level of the planning unit where the data is
entered into the HMIS database. However, as reported by many key informant interviewers and
reviewing the records at each level, the team found that the reports were late, incomplete, or
missing. Some of the districts visited have instilled a system of posting on the bulletin board the
date the report was received from the facility. The district staff reported that this has helped
monitor facilities that have not reported. Reporting compliance has also improved.
Forms Used in the System
Stock Cards are used at all levels of the system for each commodity. At the NMS, they were kept
with each product. However, in many cases they were not updated since the computer system also
keeps this data. In the districts, stock cards were also kept with the supplies or on the
storekeepers’ desk, which was usually in the store where the supplies were kept. However, many
of the stock cards were not kept up to date. A similar situation was also found at the health
40
facility level. In most of the clinics visited, the team found that there was usually not a stock card
kept for contraceptive supplies. While there is no column for losses and adjustment, most of the
storekeepers interviewed were aware that they should record it as a negative balance. None of the
records reviewed had a record entered for losses and adjustment.
Requisition and Issue Voucher are used at very level of the system to order supplies. A multiple
of three copies per order is used. The first copy stays with the facility ordering the supplies, the
other two copies are sent to the supplier. The supplier retains one copy and the third copy is
returned to the recipient with the supplies. The in-charge of the facility is usually the authorizing
signatory on the order. The form also has a column for current balance. However, in most of the
records reviewed, the team found that that column was usually not filled out. If this data were
provided, the central level would have the data on stock on hand and would be better able to
determine the inventory in the country.
Health Unit Monthly Report are used by the clinics and the districts to report to the level above.
The four-page form provides service statistics data. For family planning, the form reports on
service statistics and number of contraceptives dispensed to clients by brand. This data if reported
could be used to determine the country-wide forecasts. This report was found to be too time-
consuming and is currently being redesigned. In the new form, the family planning dispensed to
user data is being replaced by reporting by method.
Daily Registers for various services are used at the clinics level. These usually notebooks
purchased from the local market. The health workers draw in the various columns that they need.
In the case of the contraceptive register, the columns were titled in a different sequence from page
to page. This practice can result in increased errors when health workers are aggregating data at
the end of the month.
Table 7 : Logistics Records and Reports
Level
Recording and
Reporting Form
Information
Staff
responsible
Facility
record kept
Comments
Daily Register
• Rate of consumption
Provider Consulting
room
no preprinted
registers
Stock card
• Stock on hand
• Quantity received
In-charge In-charge
office
usually no
stock cards for
contraceptives
Requisition & Issue
Voucher
• Stock on Hand
• Quantity received
In-charge In-charge
office
stock on hand
usually not
reported
H
e
a
l
t
h
F
a
c
i
l
i
t
y
Health Unit Monthly
Report
• Rate of Consumption
• # of days stocked out
In-charge In-charge
office
Stock card Stock on hand
Requisition & Issue
Voucher
• Stock on Hand
• Quantity received
DDHS
Storekeeper
DDHS office
Storeroom
stock on hand
usually not
reported
Record of stockouts
• # of days stocked out
Storekeeper Storeroom usually not
reported
D
i
s
t
r
i
c
t
Health Unit Monthly
Report
• Rate of consumption
of all the clinics
aggregated
DDHS DDHS office
In line with the decentralization policies, the objective of the HMIS is to strengthen the districts’
ability to use data for decision-making and reduce the amount that is reported to the central level.
However, it would be very difficult for the district level to make logistics decisions based on the
41
current data. This is because not all the essential data items are reported to the district level; and
there is no one person responsible to pull all the data together so that it can be used to make
logistics decisions. However, assigning and training one or two people to be responsible to
compile and manage the logistics data from drugs, vaccines and contraceptives could rectify this
situation.
Impact of MOH Changes to HMIS Forms
In order to reduce work for the health workers, changes are being made to the HMIS forms so
that only essential data is collected. For family planning, the new HMIS form suggestions include
removal of reporting dispensed-to-user data by brand and replacing it reporting it by method. The
consultants believe however, these will not reduce work for the frontline worker, but in fact will
increase it. Health workers manage their daily family planning registers by brand dispensed. It
would be far easier for the health worker to count each column and transfer the number than to
get the health worker to add all the pills and then enter the number by method on the monthly
report form. If data is received by brand, it is very easy to compile data by method. However it is
impossible to determine the amount dispensed by brand if it is reported by method.
If the dispensed to user data is not reported by brand, this would ensure that the data could not be
used for projecting and improving forecasts. In many of the countries FPLM works in, the
country projections have dramatically been improved due to dispensed-to-user data available by
brand.
The following points are suggestions to the proposed changes that are planned for the HMIS.
The Family Planning Register
• In order to minimize reporting errors, it is better to have pre-printed registers.
• If funding for pre-printed register cannot be secured, staff should be trained to ensure that the column
products are same month to month. Two approaches can be used:
- alphabetically
- by the most popular brand.
E.g. insert the name of each FP commodity in the column
Client Information Amount and type of contraceptive dispensed Other
Services
Reason for
Referral
Serial No. Client
No.
Depo Microgynon Lofemenal Ovrette
Summary of Family Planning by Month and Health Unit Monthly Report
• If the form is to be sent every month, there is no need to have column for each month.
• On table two: From Operating Theatre Register, on the implant column. No. of new acceptors can be
used to determine dispensed to user data.
42
• On the table amount contraceptive dispensed, the data would be more useful if it was reported by brand.
In addition, include a few blank rows in case other brands are added.
• We suggest removing the third table in the new form and replacing it with the following
Contraceptives dispensed Dispensed
Depo Provera
Microgynon
Lofemenal
etc.
• Amount dispensed by method can easily be derived from the above reported information.
• The demand for PoP was very low. By reporting it as all pills it is difficult to use the information to
determine quantities required for each product.
• The Health units usually noted the amount they gave to CBD workers in the daily register as dispensed
and it would create more work if they were to try and separate the data at the end of each month in order
to report it. The Health units would have to consider keeping another register that recorded amount
dispensed to CBD program.
Social Marketing for Contraceptive Products
In addition to public sector distribution of free contraceptive products, the Reproductive Health
Unit of the MOH encourages the distribution of FP products through private sector firms. This is
in keeping with the MOH policy to bring contraceptive products to as broad a segment of the
population as possible and make these products as accessible as possible.
These organizations involved in social marketing of FP products conduct extensive marketing and
brand promotion, distribution and sales through wholesale and retail outlets and bring a quality
product to the consumer. In general, these products are highly subsidized, but with the eventual
goal of sustainability.
In Uganda, the two primary organizations in social marketing of FP Products are Commercial
Marketing Strategies (CMS) and Marie Stoppes International (MSI). They will be described
below.
Market share of socially marketed products has grown steadily, with quite dramatic growth seen
in some products. It was frequently reported during field visits that products that people pay for
are perceived by the purchasing client to be of higher quality. MOH officials at the field level
mentioned that they welcomed the socially marketed FP products, since these products
supplemented free supplies at the health units.
43
Commercial Market Strategies (CMS)
Deloitte & Touche manage the CMS Project, with support from Population Services International
(PSI.) CMS took over from the SOMARC Project in early 1998. SOMARC had been marketing
FP products since 1993. Contraceptive products are supplied with USAID support, and are
imported tax-free.
CMS is promoting and selling the following products; condoms, oral contraceptives, and
injectables. They are planning to introduce emergency contraceptives within the year. They also
sell impregnated bednets.
Their procurement calculations are based on sales data and expected gains or losses in sales.
Their products are imported and cleared by Kampala Pharmaceutical Industries (KPI) who
warehouse the products. KPI also overbrands – with permission – the contraceptive products for
sale and distribution within Uganda.
Eight sales agents, on commission, with 2 motorcycle re-supply couriers in Kampala to distribute
products to various sales outlets. Sales cycles are approximately 2-3 weeks, with products picked
up from the KPI warehouses and distributed personally by the sales agents. These agents also
collect any expired or damaged products for destruction. The farthest sales point is only 9 hours
from Kampala, so quick re-supply is possible.
CMS Condoms
The brand name is Protector. Three protector condoms sell for 100 UgSh (approximately 7 cents
for 3.) Sales figures since 1993 are shown in the table below. As can be seen, sales have grown
steadily. Condom supplies were interrupted in the second half of 1999, and the product was
essentially stocked out from August to December 1999. The reason for this (and other group’s
condom stockouts) is discussed in the section concerning the National Drug Authority.
In the first quarter of year 2000, condom sales have reached almost 4 million. This may partially
be a reaction to the total stockouts of the previous quarter, as commercial outlets re-supply. CMS
is projecting total sales of Protector condoms of 7 to 8 million in the year 2000.
These condoms are USAID-supplied condoms, overpackaged with the Protector secondary
packaging, containing the three condoms. The secondary packaging contains the necessary
information required by the NDA, while the individual primary packet is missing the date of
manufacture. It was agreed with the NDA that the information on the secondary packet is
sufficient for NDA requirements.
In mid-1999, CMS faced packaging and labeling issues raised by the NDA. These issues resulted
in delays of condom shipment clearance and stockouts of the CMS protector brand. These issues
are addressed in greater detail in the section on the NDA regulations, but appear to have been
resolved during this consultancy visit.
44
Table 8 : Sales History of Protector
Year Unit Sales
1993 1,812,488
1994 3,846,381
1995 5,980,285
1996 9,812,520
1997 8,962,380
1998 6,417,420
1999 4,076,880
Oral Contraceptives
The product Duofem, supplied by USAID and produced by Wyeth Industries, is overbranded and
sold as PilPlan. There are 21 tablets and 7 ferrous sulfate tablets per package per cycle and 3
cycles per package. One package sells for 250 UgSH (approximately 17 US cents.) They are
marketed through pharmacies, clinics and drug shops. PilPlan sales have increased steadily since
1993, but sales decreased slightly from 1998. It is not clear why, but consumers may be switching
to injectables.
CMS is the only organization socially marketing oral contraceptives. They “compete” only with
other types of pills supplied free from the public sector, including Lofemenal, which is essentially
the same product formulation as the Pilplan products. PilPlan has a 53% market share with 47%
other pills from the private sector. Sales are projected for 685,000 cycles in the year 2000.
Table 9: Sales History of PilPlan
Year Unit Sales
1993 66,026
1994 220,980
1995 309,743
1996 401,460
1997 517,860
1998 645,780
1999 625,860
Injectaplan
Injectaplan is a Depo-Provera product, supplied by USAID. Distribution was started in 1996, with
dramatic jumps in sales in 1998 and 1999. (See tables below.) Injectaplan is sold for 500 UgSH,
approximately 30 US cents, and is effective for a 3-month period. They come complete with an
injector, which must be brought to a qualified medical clinician, but this does not seem to be a
problem.
Sales were projected for 0% growth in 2000 , with 20,000 units a month expected to be sold. This
would mean target of 240,000 units in 2000. The current market share is 29%, with 71% through
the public sector.
45
Table 10: Sales History of Injectaplan
Year 1996 1997 1998 1999
Unit Sales 4,140 50,820 138,190 144,000
Other Products
CMS is currently marketing impregnated bednets through commercial outlets throughout the
country.
The are expecting to introduce on a pilot basis sales of an emergency contraceptive product
within a few months.
Summary
With regard to logistics, CMS is essentially an independent system. They forecast commodities,
arrange procurement through USAID, clear and warehouse products through Kampala
Pharmaceutical Industries, and distribute the products through the CMS system of sales agents.
An extensive marketing promotion supports the sales of these products.
Sales of Depo Provera are increasing dramatically, and can be expected to continue to increase.
Sales of oral contraceptives have shown a slight decrease in coming years. Sales of condoms have
increased regularly (taking into consideration major stockouts in 1999,) and can be expected to
continue to increase.
Because of the large volume of condoms, oral contraceptives and injectables that pass through the
CMS (and MSI) social marketing systems, their efforts increase availability and accessibility of
contraceptive products at all levels. In any national strategic planning, social marketing must be
calculated as part of overall commodity requirements, tracked as method mix and adjustments
made in forecasting and commodity procurement.
Recommendations:
1. Commercial Marketing Strategies should continue as part of the larger MOH FP logistics
stakeholders group to improve and expand on timely information sharing.
2. The NDA requires not only product registration, but packaging registration. Any changes in
packaging details must be registered as well. It will be important to insure all packaging
registrations are kept current to eliminate possibility of supply interruption because of
packaging or labeling issues.
3. USAID should inform CMS and NDA of any changes in product specifications or in
packaging and labeling information. This should be noted on the USAID NEWVERN
procurement tracking system notes.
4. USAID and CMS should crosscheck door-to-door payments made to Panalpina (the USAID
delivery agent) with clearance and final delivery costs paid to KPI.
46
Marie Stopes International - MSI Uganda
MSI- Uganda provides an extensive range of family planning services and counseling. Recently
they have become an active player in the social marketing of male and female condoms.
MSI started marketing male condoms in January 1997. The primary brand is Lifeguard, though a
smaller number of studded condoms are marketed under the Pleasure brand. Condom sales are
recorded in the tab le below.
Table 11: Sales History of LifeGuard Condoms
Year 1997 1998 1999 2000
Unit Sales 7,024,080 12,209,280 12,000,000 (estimate) 15,000,000 (target)
The Lifeguard condoms are produced by the LIG group/India and supported by KfW. The
condoms are sold in a packet of 3, for 100 Ugsh, the same as the CMS product. They are
overpackaged at the point of manufacture. The Lifeguard brand is supported by extensive
marketing and promotion campaigns.
Forecasting is done based on monthly sales, and sales figures are available for each outlet. Sales
projections for the year 2000 are targeted at 15 million condoms, a 25% increase. Sales figures
might be slightly skewed since CMS condoms were not available for the later half of 1999, so
sales should be tracked to be sure this 25% increase is not an over-projection. MSI tries to keep a
6-month stock-on-hand. Their supplies are kept at KPI warehouse and they do their own customs
clearance.
As with all other importers of condoms, MSI faced quality and clearance issues with the National
Drug Authority in 1999. This resulted in destruction of some condom supplies, stockouts and
slightly reduced sales in 1999 from 1998. These issues seem to have been resolved.
MSI has also been experimenting with the social marketing of female condoms. This started in
May 1997. Sales have slowly increased, with monthly sales averaging 200-800 a month, with
total sales as of Jan 1999 of 8,250 units. With low monthly sales and a total of 1.2 million
condoms brought into the country in 1997, there is an oversupply of female condoms at current
consumption rates and will probably expire.
As in other countries, the social marketing of female condoms is being done on a pilot basis. It
requires more extensive client and provider information and training than other products.
Summary
MSI maintains an independent logistics system for their male and female condoms. Forecasting,
clearance, warehousing, distribution and sales are done through their own separate systems.
However, their work impacts greatly on condom availability and accessibility. Between CMS and
MSI, 1999 sales were almost 15 million condoms, at a time of major condom stockouts for both
groups. With projected year 2000 sales for both groups, this is approximately 50% of the total
estimated condom use in Uganda.
47
Recommendations
MSI should be a part of an expanded stakeholders group so there is a up-to-date information
exchange about product availability, method mix and use in the country.
Use of female condoms should be tracked closely. It is likely that large quantities will expire in
2002, if consumption rates do not increase.
Private Sector Contraceptive Products
Beta Health Care markets the Durex brand condom, with 1999 sales of 120,000. Their cost per
condom is 833 UgSH (approximately 55 US cents each.) Since socially marketed condoms cost
33 UgSH each, this is designed for a specialized, upscale market. MacNoughton sells a Rough
Rider condom for the same price, with 1999 sales of 233,000. The market share for upscale
condoms is insignificant and should not effect public sector or socially marketed condom
projections.
No information is available for true private sector sales of oral contraceptives, but this market is
not being targeted by the public sector or by and socially-marketed product.
Family Planning Association of Uganda
The FPAU is the oldest family planning group in Uganda, having been operating for 48 years.
They have 28 branches in 23 districts, but will likely be consolidating with six regional centers
and a greater emphasis on community-based services. They provide both long-term and short tem
Family Planning choices, MCH ante and post-natal care, counseling and treatment for STI, post
abortion care and both prevention counseling and treatment for HIV/AIDS patients.
They provide a wide range of contraceptive products with an extensive method mix. They receive
many of their supplies through the IPPF, but can also acquire or purchase supplies locally. For
imported supplies, they do their own forecasting, procurement, clearing, warehousing and
shipment. They have a lorry for supply delivery, and use a private commercial company for
emergency shipments when necessary. Distribution to their clinics and outlets is by pull basis,
with distribution quarterly. They operate on a manual stock tracking system, and are interested in
a computerized system.
The consultants identified a large number of IUDS in FPAU possession, which would not have
been used and would expire in early 2001. Since the Ministry of Health was completely stocked
out of IUDS, and other programs such as MSI needed these immediately, a mutually beneficial
transfer of usable IUDS was arranged by the Reproductive Health Unit and started immediately.
This demonstrates the real value of an expanded stakeholders group, which could share
information and products across systems on a regular basis.
48
Recommendations
This section will group recommendations by the key responsible agency in order to help track
decisions and actions taken by each group. Some recommendations are duplicated since they will
apply to several agencies, in identical or similar ways. This also fulfills the requirement in the
consultant’s SOW to organize recommendations by individual implementing groups.
The Reproductive Health Unit of the Ministry of Health
A. Contraceptive Security – provision of adequate supplies – needs to be closely tracked,
especially as donors shift to Sector Wide Allocation programs. Continuity of supplies must be
ensured during this transition period and adequate contraceptive supplies included in the
SWAP budgeting. The Reproductive Health Unit, supported by donors and logistics technical
assistance, must be responsible for the inclusion of supplies planning. At the present time,
with ordered supplies included, there is at least a 2-year supply for most contraceptive
products. Now is the time to plan for beyond two years, using 2001 CPT projections.
Projections can be updated also with DHS data due in February 2001 and the Population
Consensus in 2002.
B. As allocations are made in the SWAP budgets, the RH Unit must work closely with the donor
agencies to be certain sufficient funding is included for contraceptive commodity
procurement and for their distribution. Since this is a new and evolving system, this process
must be tracked closely to monitor procurement funding levels. It would seem that the
Population Secretariat would be a useful ally in this process.
C. UNFPA funding will not be know until January 2001 at the earliest, so their possible support
must be calculated in then, if applicable.
D. The Reproductive Health Unit with external technical assistance should do CPT commodity
forecasting in July 2000 for the year 2001 and beyond. It should use all possible data sources
including demographic projections, DISH District survey data, 200 site dispensed to user data
and HMIS monthly form to produce projections.
E. We believe USAID will be able to support a two-week consultancy the end of July to have
technical assistance from FPLM to help conduct this extensive review and develop detailed
contraceptive need projections. FPLM technical assistance is also available at any time for
long-distance consulting or technical review on CPT forecasting or forecasting changes.
F. The Contraceptive Coordinating Committee should have a formal meeting every 4 months,
coordinated by the RH Unit. This would review stock-on-hand data, shipment coordination,
issues data, problems that arise, and information and product status that need to be shared.
This meeting should include all donors and potential donors, all social marketing distributors,
49
all providers of family planning services, the National Medical Stores and MOH sections
such as Reproductive Health, ACP, HMIS and the NDA.
G. Regular meetings would focus attention on stock status and future needs, identify problem
areas as they arise and permit information and even product exchange between stakeholders
to mutual advantage.
H. The Reproductive Health Unit should coordinate this meeting, but the DISH project has
generously offered to provide secretariat and other support to help coordinate this important
meeting. Having this meeting three times a year seems to be an effective timeframe in other
countries within the region.
I. Technical Assistance in Logistics planning and advocacy should be provided to the
Reproductive Health Unit from specialized external expertise and with on-going local
logistics support, primarily from the DISH project. This combination would strengthen the
capacity of the RH to coordinate forecasting, procurement and district level improvement.
The DISH II Project will provide technical assistance and funds to the district in improving
district level inventory control/ordering procedures and storage in the 12 DISH supported
districts.
J. External technical assistance under the direction of the RH Unit would be very productive to
help verify CPT forecasting, assist in the development of procurement guidelines, coordinate
improved District level inventory control and ordering procedures, improve storage
procedures, assist in the integration of logistics systems and bring in regional experience. If
this were able to be provided, the RH Unit could request specialized experience from within
the region or internationally. There is excellent regional expertise available from Nairobi,
which would be accessible on short notice.
K. The DISH project offers both advocacy and policy support and follow-up on the national
level and hands-on knowledge of logistics activities at the District and Health Unit level
within their 12 focus Districts. They will be conducting a detailed logistics survey in mid-
2000 and this knowledge will be useful for the RH Unit in planning District level systems and
approaches.
L. Specific project activities, including DISH, CARE, UNFPA and others, can be used to
promote RH Unit objectives is supporting logistics systems at the District level.
M. The ten percent handling fee on the value of commodities, due to the NMS for handling,
storing and shipping supplies to the District level, is such an obstacle to a smooth and
efficient ordering process that it should be made a guaranteed payment and taken out of the
ordering approval process.
Options to do this range from
1) RH securing guaranteed funding;
2) donors prepay this 10% when commodities are received by the NMS,
3) a guaranteed amount be authorized by line item in the Sector-wide planning budgets
or
4) a guaranteed amount be included in the Health Sector Debt-relief budgets.
district level ordering will not improve perceptively until this 10% handling fee issue
is resolved.
50
N. Immediately, the RH Unit should track their request for 272 Million Uganda Shillings for
commodity clearance which has been submitted to the Ministry of Finance. If this should not
be allocated, or if it is allocated in a significantly smaller amount, this information should be
shared with relevant donors to explore what other options might be possible.
O. The RH Unit should request from the NMS a detailed breakdown of the past unpaid and
anticipated 10% handling costs for contraceptive delivery so that the donor agency could
make provisions for this payment if possible.
P. RH and donors need to ensure dispensed to user data is maintained in the new HMIS forms.
Q. The HMIS forms are being revised at the moment. Logistics planning information is in
danger of being lost. Recommendations for the revised forms are attached in an appendix, but
the RH Unit and the donor organizations should track this development.
R. All contraceptive commodity importers must ensure that not only is the product registered
with the NDA, but that packaging and labeling must meet NDA specifications. Any changes
in packaging or labeling requires notification to the NDA.
S. if for any reason, USAID procured condoms are requested for the public sector in Uganda,
the RH unit must obtain in advance a waiver from the NDA for the importation of these
condoms.
T. If provided with a clear delivery order from the MOH and payment for services, the NMS has
the facilities, transportation and human resources to deliver contraceptive and other medical
supplies to the District level in a timely and efficient manner.
U. Dispensed to user data from a previously conducted 200 site survey should be entered and
analyzed. This work could be coordinated by the DISH project and be used in calculating the
2001 CPT report.
V. RH unit should use Pipeline software to assist in the procurement planning. This can be
installed by FPLM with training provided. Back-up technical assistance is always available
for the use of this system. Several individuals should be trained in Pipeline use.
W. Pipeline tracking of stock status would be a useful component of regular stakeholders
meetings.
X. The RH Unit can request technical assistance for contraceptive procurement in procedures,
specifications and quality control.
Y. RH and other key officials would benefit from the three-week Arlington logistics training
course. It would be important to develop a cadre of trained officials who could mutually
support the development of an improved logistics system. Two officials should be sent to the
next available training course.
.
51
I. RH and MOH Activities at the District and Health Unit Level
A. Expired Stock and damaged materials should be collected and removed from health unit and
District level storage areas. With prior notification to the Districts to collect expired products
to the District level; a truck could be sent to each district to collect expired contraceptive (and
drug) products. An authorized official from the MOH should be involved to receive, report
and sign for these products.
B. The NMS has developed a proposal for the removal of these expired products to the national
level.
C. Storage facilities need to be upgraded especially at the district level. The MOH should
encourage Districts and District-specific projects to provide minimal resources such as
shelving and paint to improve storage areas. One day’s worth of time to organize stocks and
train storekeepers in simple procedures would help substantially.
D. With the construction and re-furbishment of sub-district centers, simple plans for a functional
storage area could be developed. For example, built-in concrete shelves seen at some centers
were inexpensive and very effective. A minimum space requirement should be developed.
E. Basic storage job aides should be developed, disseminated and trained. This can be done with
FPLM and DISH assistance.
F. Procedures manual need to be developed for District and other level inventory control and
stock ordering. The Process should include the following:
- design workshop to achieve agreement on procedures and forms
- development of training manuals and on-the job training aids
- testing of training in DISH and other project areas
- inclusion of logistics training in other training packages
- training of both policy decision makers and operational cadre
- emphasis on dispensed to user data for decision making
G. This work should be coordinated with the drug project supported by DANIDA and forms.
Systems and approaches should be developed in common.
H. Contraceptive and other commodities need to be synchronized to the quarterly distribution
cycle of Essential Drug kits, once procedural obstacles are eliminated and staff trained to
manage inventory and ordering.
I. Define role of sub-District health center in logistics activities. The consultant’s initial
recommendation would be to avoid stock storage at this level.
J. Design and institute a system to re-distribute commodities in oversupply
52
USAID and Other Donor Organizations
A. Contraceptive Security – provision of adequate supplies – needs to be closely tracked,
especially as donors shift to Sector Wide Allocation programs. Continuity of supplies must be
ensured during this transition period and adequate contraceptive supplies included in the
SWAP budgeting. The Reproductive Health Unit, supported by donors and logistics technical
assistance, must be responsible for the inclusion of supplies planning. At the present time,
with ordered supplies included, there is at least a 2-year supply for most contraceptive
products. Now is the time to plan for beyond two years, using 2001 CPT projections.
B. As allocations are made in the SWAP budgets, the RH Unit must work closely with the donor
agencies to be certain sufficient funding is included for contraceptive commodity
procurement and for their distribution. Since this is a new and evolving system, this process
must be tracked closely to monitor procurement funding levels. It would seem that the
Population Secretariat would be a useful ally in this process.
C. Donor Procurement should involve the National Drug Authority in procurement planning,
especially with new commodities, new manufacturers or even new labeling, to avoid
clearance delays and possible exclusion of products. This should be done at the time of
commodity procurement, not when supplies have arrived in country.
D. USAID should consider providing support for specialized external technical assistance on a
regular basis
E. USAID should encourage and support DISH participation in logistics advocacy and policy
discussions and decisions at a national level. This would be a useful and effective use of
different aspects of USAID technical assistance.
F. USAID/Washington should note in the Newvern system (worldwide commodity procurement
tracking system) that any changes in product, manufacturers or packaging must be notified to
the NDA. And to USAID/Uganda.
G. USAID/ Washington should consider adding the Date of Manufacture to each condom
primary packet, at the time of the next worldwide production contract. This would comply
with WHO specification guidelines and conform to other condom labeling.
H. FPLM and USAID/Washington should send to NDA all agreed upon documentation and
FPLM should provide USAID-supplied products documentation and sample folder.
I. USAID/Washington should review shipping and payment instructions with Panalpina and
with Kampala Pharmaceutical Industries.
J. Donor Organizations and FPLM should encourage Uganda participation in RLI regional
logistics activities.
53
DISH Project
A. Use resources of DISH Project and other projects to advocate for, test and support
implementation of inventory and ordering capacity building at the District level.
B. Use Supply Chain Manager computer system for inventory control and ordering in DISH
Projects. Encourage expansion of logistics lessons learned in DISH focus districts to other
project-assisted Districts.
C. Provide a small fund for re-furbishment and improvement to District level storage areas and
provide training to storekeepers in simple storage improvements.
D. Support the RH Unit in encouraging and coordinating a stakeholders meeting for logistics
every four months at the national level.
Other Stakeholders
A. Actively Participate in a national-level logistics stakeholders meeting every four months.
B. Notify and receive approval from the National Drug Authority for product packaging and any
changes in product packaging.
C. There are a large number of female condoms in Uganda. With current levels of consumption,
there is more than a hundred years of supply. Even allowing for greatly improved
consumption rates; it might be advisable to consider “marketing” supplies that will not be
used to other countries.
54
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Situation Analysis Conducted by IRC Reproductive Health Consultant. Washington, D.C.:
International Rescue Committee.
57
Appendix 1: Scope of Work
ASSESSMENT OF THE CONTRACEPTIVE LOGISTICS SYSTEM IN UGANDA
FAMILY PLANNING LOGISTICS MANAGEMENT PROJECT
Background
USAID/Uganda supports reproductive, maternal and child health programs in Uganda through
various strategies. These include increasing service utilization and behavior change by increasing
availability, improving quality, knowledge and perceptions and enhancing sustainability. In
addition, USAID supplies substantial contraceptive commodities for the entire country.
Availability of contraceptive supplies is an essential element in the delivery of quality, integrated
reproductive health services. Contraceptives in Uganda are procured through a limited number of
donors (USAID, UNFPA and DfID in particular) and provided to the Central Ministry of Health
(Reproductive Health Division) for their distribution to the District Health Offices and other
institutions responsible for service provision. Distribution from central to peripheral level
involves an intermediate storage step with the National Medical Store (NMS), a para-statal
institution responsible for drug purchase, storage and distribution at national level.
Over the last two years, repeated stock outs of contraceptive supplies have been registered at
national, district and facility levels. Several logistics issues that may possibly hamper the
programs’ success in ensuring that the products such as contraceptives are available for
distribution were identified, including:
Delays in-country procurement clearance resulting in a shortage of condoms and potentially
an expiration of expensive STI drugs and reagents due to outstanding handling fees owned to
the NMS.
Current limitations of donor coordination approaches, as shown by the unexpected
termination of Norplant supply by the UK.
The same distribution system is currently handling the all the free and cost-recovery products.
There is problem in ensuring that the products that are provided for free are used for the
intended purpose and not sold. It is difficult to achieve this, as the same products are also
available in the cost-recovery program.
Decentralization of health services has resulted in lack of information at the central level to
plan for procurement. In addition, it is also unclear whether there are sub-standard products
that have filtered in the system, due to lack of trained staff at the lower levels in procurement
procedures.
Poor quality of drugs/contraceptive storage and needs assessment at district and facility
levels.
Monitoring of CYP provided by the public sector institutions has shown a marked decrease
during 1999, when condoms went out of stock all over the country for more than six months and
injectable contraceptives showed a similar trend at the end of the year. While a shift towards the
58
private sector as the preferred source of contraceptive – at household level - may be taking place
currently and account for part of this trend, the MOH Reproductive Health office, USAID
Mission and the DISH Project are worried that potential stock outs of contraceptive and other
supplies may prevent the achievement of the objectives of increased availability and quality of
reproductive health services. Within this context, they would like to request the Family Planning
Logistics Management Project to conduct, in coordination with MOH, DISH, CMS and other
partners, a systematic assessment of the contraceptive procurement system in Uganda.
Goal of the Assessment
To conduct a qualitative and quantitative assessment in order to formulate recommendations to
improve the efficiency of the logistics system based on the data gathered on the current status of
the contraceptive logistics system. The assessment will include the complete in-country supply
chain, i.e. all tiers of the system and will review all functions of logistics; procurement,
distribution, transportation, warehousing, inventory control and LMIS.
While the assessment will focus on the contraceptive logistics system, where feasible, the team
will also collect data on logistical aspects of essential drugs, vaccines, vitamin A, iron
supplements, STD drugs, TB drugs, drugs for opportunistic infections related to AIDS and other
public health commodities.
Specifically, the assessment will provide an understanding of the comprehensive issues with the
current contraceptives logistics system in Uganda and provide at set of specific recommendations
to facilitate an adequate and timely supply of contraceptives over the coming five years.
Objectives of the assessment
1. To assess the status and function of the logistics-based activities of key partners at all
levels of Uganda supply chain for reproductive health supplies and critically review the
current structure of the various supply chains currently operating in Uganda , with
particular attention brought to the following issues/problems:
- past procurement patterns, intentions of current donors and availability of
funding over the coming five years;
- Ministry of Health intentions/plans with regards to contraceptive procurement
with national/district funds and proposed move towards a “pull” drug
procurement system;
- relationships between the various institutions (MOH, NDA, NMS, JMS, CMS,
districts and others) involved in storage and distribution of donor-procured
contraceptive supplies, in particular with regards to:
- legal requirements for importation/packaging of pharmaceutical
products, in particular contraceptive supplies
- responsibilities of central MOH and districts vis-à-vis storage and
handling fees
- definition of procedures for procurement of contraceptives from the
district level (that is, which institution is responsible for supplying the
districts and facilities?)
- adequacy of the current contraceptive needs assessment process at national and
district levels
- the perception and position of the National Drug Authority about social
marketing and community-based distribution programs, and the problems faced
59
by these subsidized programs in the procurement, clearance and distribution of
contraceptives with respect to the requirements of the NDA
- existing contraceptive logistics and management practices and networks of CMS,
Marie Stoppes and FPAU with respect to the established MOH drug logistics and
management system
- adequacy of existing human resource at the MOH for performing its core
functions related to drug/contraceptives logistics and management.
2. To gather and review logistics indicators for all levels of the MOH system for
contraceptives
3. To identify the main causes of recurrent stock outs of contraceptive supplies, identify
areas that need to be strengthened or streamlined in order to improve the flow of the
product through the systems and suggest operational solutions to ensure the timely and
sufficient provision of these supplies through the coming five years.
4. To estimate, from a review of the previous Contraceptive Procurement Tables and from
the findings of the assessment, the needs for contraceptive supplies over the next years,
both at national level and in the 12 DISH and 3 CARE districts (based on a 1% projected
annual increase in CPR at national level and 1.5% in the DISH-supported districts.
5. In addition, the assessment team should help the DISH Project identify those
issues/problems/ constraints related to contraceptive procurement that are equally
relevant to the overall drug procurement system in Uganda; and provide advice, based on
its experience in this area, on the feasibility of extending the current computerized
commodity tracking system to a wider range of products (in particular, IMCI-related
drugs, Vitamin A, Iron, vaccines and other selected public health commodities).
Planned Output of the Assessment
1. A report on the status of the current funding, procurement, clearance, storage,
distribution, sales and LMIS for contraceptive supply in Uganda and existing failures or
constraints.
2. An estimate of the quantities of contraceptive supplies (per method) needed over the next
five years for the country, and for the DISH and CARE-supported districts.
3. A set of operational recommendations aimed at facilitating an adequate and timely supply
of contraceptives over the coming five years; these recommendations should be
specifically directed to:
- the USAID Mission
- the Ministry of Health and other government or parastatal institutions involved
- the DISH Project
- the CMS Project
Timing and duration
It is agreed that the study shall begin on May 1 for a duration of three weeks.
Assessment Team
Two FPLM staff will work in collaboration with the MOH, DISH-II project and other donor
partners to conduct the assessment. Prior to the arrival of the FPLM staff, DISH-II will assist in
60
gathering some preliminary data, help with setting up a schedule for the team, identify the sample
size and participating on the team itself.
The team will also work closely with Bonita Blackburn/USAID/W to coordinate the resolution to
the procurement issues and their potential impact to the contraceptive logistics system.
Methodology/Strategic framework of the Assessment
The assessment will gather qualitative data through key informant interviews and quantitative
indicators to assess the overall status of the logistics system. The logistics cycle will be used as a
framework. Data will be collected on the entire in-country supply chain from the central level, all
the way to the clinic where the product is dispensed to the client.
In addition to the standard assessment, the team will use the Logistics Performance Matrix
1
used
by many private sector companies to assess the performance of each of the components of the
logistics system and of the overall status of the supply chain performance. Performance indicators
will be gathered where possible on Quality, Productivity and Response Time on each of the
activities of the logistics system. This data will inform managers, operators, and designers on
their current performance in each of the logistics activity and enable them to set targets to
improve the logistics system. If the data can be gathered, it can be used to at least set up an
internal benchmarking program among the different regions or districts.
Note: the DISH Project plans to conduct in May and June 2000 a district-level assessment of the
drug logistics systems which should complement the proposed assessment, as well as the Drugs
for Management of Childhood Illnesses (DMCI) study undertaken by the Rational
Pharmaceutical Management (RPM) Project. Accordingly, the FPLM team may focus its efforts
on national and central level logistics and management issues.
Focal Persons
Dr. Vincent David of DISH-II and Ms Annie Gaboggaza-Musoke of USAID will be the focal
person to oversee the implementation of this assessment. Before and during the assessment, the
DISH Project staff will also identify and make appointments with relevant persons and
institutions; review the trends of past funding of contraceptive supply in the country; compile
existing literature on drug procurement
studies in Uganda and brief FPLM team upon arrival.
Addendum for Bonita Blackburn, USAID/W
It is our understanding the Ms Bonita Blackburn from USAID/W will join the FPLM team. We
would like to take the golden opportunity to increase common understanding and expectation
among USAID/W, USAID/Uganda and sleeted USAID implementing partners including CMS
and DISH about CPTs and critical issues with NDA regarding procurement, clearance and
distribution of drugs and contraceptives. Accordingly, we would appreciate that Ms Blackburn:
1) review and discuss CPTs and related problems and recommend revisions USAID and CMS
2) review and revise roles and responsibilities for development and monitoring of CPTs with
USAID and CMS
1
Frazelle Edward, Logistics Performance, Cost and Value measures. 1999. Penton Media Inc.
61
3) Familiarize her with NDA procedures and pitfalls,
4) Present USAID procurement to NDA and the MOH with CMS
5) review shipping documents and procedures with USAID,KPI and CMS).
Proposed Institutions to be contacted/visited
Government institutions
Ministry of Health
Headquarters of the Ministry of Health: responsible for policy formulation, implementation and
supervision. This will include clinical services, Pharmaceutical division. Reproductive Health
project, Logistics section, etc.
NMS – National medical stores: A parastatal drug procurement and distribution corporation,
involved in the handling, storage and distribution of drugs and contraceptives mainly for the
public sector.
Ministry of Local Government – Decentralization secretariat: Oversees district health services
under the decentralization scheme.
Uganda Local Authorities Association
NDA – National Drug Authority: The national drug regulatory agency. Formulates drug policies,
regulates drug imports, drug use, issues national drug use guidelines and sets standards.
Uganda Peoples Defense Forces
Service delivery centers including Hospitals (including Mulago, Regional District referral,
District, NGO, HC IV, HC III, HC II)
Donors
DANIDA: Funds health related programs like Health sector support program (HSSP) and
essential drugs support program (EDSP)
UNFPA Funds the Reproductive Health (RH) project that carries on Reproductive health
services in about 26 districts. Funds substantially the supply of contraceptives in the country
EDSP Funded by DANIDA. Funds rural drugs/drug kits
DfID Funds procurement of contraceptives. Supports collection of data needed for
contraceptive projections
USAID
Projects/NGOs
HSSP: Supports the training of medical assistants & equipping paramedicals, supports
implementation of HMIS and supports the quality assurance unit
62
STIP – Sexually Transmitted Infections Project: Funded by among others the World Bank. It
operates countrywide. It is involved in the prevention of sexually transmitted diseases, care
for the people with AIDS and the other related diseases.
DHSP – District Health Services Program: Funded by World Bank, KfW, SIDA, and GoU.
Supports capacity building in district primary health care services.
JMS - Joint Medical Stores: Christian founded drug procurement NGO involved in drug
storage and rational drug use promotion.
CMS – Commercial Market Strategies: involved in social marketing of condoms, oral and
injectable contraceptives, STI treatment kits.
MSI - Marie Stoppes International: CNS competitor, also involved in social marketing of
contraceptives
Others
Districts- Involved in drug logistics and management
KPI – Kampala pharmaceuticals industries: Manufacture of drugs, packaging of commodities
e.g. protector condoms for CMS.
Association of Drug Importers
WHO - Involved in various fields: PHC, disease control, malaria and tropical diseases,
women and children health, health information, nutrition, environmental health, non-
communicable diseases. Very influential on MOH policy development and standard setting
63
Appendix 2: The Logistics Cycle
Product Selection
Procurement
Use
Distribution
Management Support
Organization
Finance
Information Management
Human Resources
64
Appendix 3: Schedule for FLM/USAID Assessment Team
May 2 – 19
th
, 2000
Tuesday, May 2
8:30am USAID Kampala briefing
Angela Lord, Rebecca Rohr, Annie Kaboggoza-Musaki, Betty Nabirumbi
10:30am Reproductive Health Unit
Dr. Florence Ebanyat, Dr. E.F. Katumba, Dr. Bazirake (UNFPA)
1:30pm DISH II Project
Dr. Vincent David, Eldad Sebagenzi, Dr. Stembile Matutu, Charles Katende
3:15pm Kiswu Clinic, Kampala
Daisy Okuma
4:00pm STI Project
Dr. Peter Nsubugu
Wednesday, May 3
8:30am DISH II Project
Dr. Souleymane Barry, Dr. Vincent David, Eldad Sebagenzi
11:00am Commercial Marketing Strategies (CMS)
Elizabeth Gardner
1:30pm National Drug Authority
Dr. John Lule, Francis Otim, Gabriel Kaadu
4:00pm DFID
Ros Cooper
Thursday, May 5
8:30am USAID
Angela Lord, Rebecca Rohr, Betty Nabirumbi
9:30am UNFPA
Fabian Byomuhangi
11:30 CMS
Dr. Peter Crowley, Elizabeth Gardner, Rebecca Rohr
2:00pm HSSP/DANIDA Project
Sjoerd Postma
Friday, May 5
9:00am National Medical Stores, Entebbe
Patrick Kisitu, Saul Kidde, David Kubagenda
3:30pm Marie Stopes Intl.
Judith Butagira
4:30pm DISH II Project
David Vincent
6:00pm Regional Quality of Care Center – Makerere U.
Shelia Magero, Tom Kakaire
Monday, May 8
9:00am USAID
John Cutler
10:30am DISH II
Muyingo Sowedi
65
1:30pm Joint Medical Stores
Wim Mensink
3:30pm Uganda Midwives Association
Charlotte, Gideon Nzoka
4:30pm Family Planning Association of Uganda
Dr. Paul Kabwa
Tuesday, May 9
9:00am DMS, Ministry of Health
Professor Omaswa, Dr. Ebanyat
11:00pm Depart for field
3:00pm Kamuli District Office
DHV, Nurse, Storekeeper
4:30pm Level Four Clinic
Kamuli Nurse, Storekeeper
Wednesday, May 10
9:00am Pallisa District Office
DHO, Nurse, storekeeper
11:30am Buseta Clinic – Level III
Doctor, nurse, storekeeper
3:30pm Mbale District Office
DMO, nurse, storekeeper
4:30pm UNFPA Regional Office
Regional coordinator
Thursday, May 11
9:00am Budadiri Clinic Level III
Doctor, nurse, storekeeper
11:30am Buwalasi Clinic Level IV
DDHS, nurse, storekeeper
1:30pm Iganga District Office
Nurse, storekeeper, records
3:00pm Muyunge Health Center –III
Doctor, nurse, storekeeper
Friday, May 12
9:30am DISH II Project
Souleymane Barry, Muyingo Sowedi
11:00pm USAID
Betty Nabirumbi, Annie Kaboggoza-Musaki
2:00pm USAID
Dawn Liberi, Patrick Fleuret, Angela Lord
Monday, May 15
9:00am World Bank
Peter Okwero
10:30am CARE
Louis Alexander, Dr. T. Makwate
66
Tuesday, May 16
9:00am NMS- Inventory Count
Saul Kidde, David Kubagenda
1:30pm UNEPI
Isingoma Patrick, Winifred Tabaaro, Zura Asander, Kurasi Beim
2:30pm Geographic Mapping Survey Department
Wednesday, May 17
9:00am Ministry of Finance
Magona Ishmael, Steve Rice, Annie Kaboggoza-Musaki, Betty Nabirumbi
11:00pm USAID
Patrick Fleuret, Angela Lord, Anne Kaboggoza-Musaki, Betty Nabirumbi, John
Cutler
6:00pm Regional Center
Joel Okullu
Thursday, May 18
10:00am Population Secretariat
Dr Jotham Musinguzi, Nahabwe Paddy, Rhobbinah Ssempebwa
Charles Zirarema,
11:30am CMS
Peter Crowley, Elizabeth Gardner, Sarah Margiotta, Angela Lord, Annie
Kaboggoza-Musaki.
10:00am Reproductive Health
Dr. Katumba
2:00pm Stakeholders Meeting
Dr. Mbowye, Dr. Katumba, Karl Kulessa, Dr. Bazirake, Ros Cooper, James
Thornberry, Annie Kaboggoza-Musaki, Betty Nabirumbi, John Cutler, Dr.
Souleymane Barry, Muyingo Sowedi, Dr. Vincent David, Chris Forshaw, Dr.
Joel Okullo, Wim Mensink, Elizabeth Gardener, Sarah Margiotta, Steve Wilbur,
Sangeeta Raja
Friday, May 18
9:00am Reproductive Health Unit
Dr. Katumba
11:00am USAID
Angela Lord, Annie K., Betty N.
11:30am DFID
Ros Cooper
12:00pm DISH II Project
Souleymane Barry, Muyingo Sowedi
67
Appendix 4: People Contacted
Uganda country code: 256 Kampala: 41 Entebbe:
Ministry of Health
P.O. Box 7272, Kampala, Uganda
Tel: 256-41-231563/9
Fax: 256-41-340881
Title Name Email Contact Number
Director General Health
Services
Francis D. Omaswa [email protected] Tel: 340881
Assistant Commissioner,
Reproductive Health
Dr. Florence Ebanyat [email protected] Mob: 077 413485
Principal Medical officer Dr. E.F. Katumba Tel: 340874
Project Manager (STIP) Dr. Peter Nsubuga [email protected]
Tel: 340884
Fax: 340877
Ministry of Finance, Planning & Economic Development
Infrastructure & Social Services Dept.
P.O. Box 8147,Kampala, Uganda
Tel: 256-41-235051/4
Fax: 256-41-251793
Assistant Commissioner Magona Mweru Ishmael [email protected]
Health Economist Steve Rice [email protected] Mob: 077 469511
Ministry of Finance, Planning & Economic Development
Population Secretariat
Crane Chambers
Plot 38 K’la Rd.
P.O. Box 2666, Kampala, Uganda
Tel: 256-41-342292
Fax: 256-41-343116
www.uganda.co.ug/population
Director Dr. Jotham Musinguzi [email protected] 343356
National Programme
Officer, Head Socio-
Economic Monitoring
Dept
Nahabwe W. Paddy [email protected] Mob: 077 420446
National Programme
Officer, Head Family
Health Dept.
Rhobbinah Ssebbowa
Ssempebwa
[email protected]
National Programme
Officer, Head policy &
Planning Dept.
Charles Zirarema [email protected] Mob: 077 456011
USAID/Uganda
Plot 42 Nakesero Rd
Kampala, Uganda
Tel: 256-41-235879
Deputy Mission Director Patrick Fleuret [email protected]
Chief, Office of
Population, Health and
Nutrition
Angela Lord [email protected] Mob: 077 221228
Rebecca
Annie
Project Management
Assistant
Betty Nabirumbi [email protected]
Senior Health Advisor Dr. John Cutler [email protected] Mob: 075 721101
68
DISH
Plot 20 Kawalya Kaggwa Close
Kololo
P.O. Box 3495, Kampala, Uganda
Tel: 256-41-344075
Fax: 256-41-250124
Chief of Party
Dr. Souleymane
Martial L. Barry
[email protected]
Health
Management/Quality
Assurance Advisor
Dr. Vincent David [email protected] Mob: 077 221324
Research & Evaluation
Advisor
Charles M. Katende [email protected] Mob: 077 409756
Logistics/Financial
Management Specialist
Muyingo Sowedi [email protected] Mob: 075 652862
Planning/Management
Coordinator
Eldad Sebagenzi Mob: 077 458324
National Medical Stores
plot 4-12 Wilson Rd
P.O. Box 16, Entebbe, Uganda
Tel: 256-41-321323
Fax: 256-41-321469
Ag. General Manager Patrick Kisitu [email protected] Mob: 077 771336
Head Stores/Logistics Saul Kidde [email protected]
Stores Supervisor David Kubagenda
HSSP
MOH/DANIDA
MOH Complex
Plot 6 Lourdel Rd.
Kampala, Uganda
Tel: 256-41-235477
Fax: 256-41-235478
Chief Technical Advisor Sjoerd Postma [email protected]
HSSP
MOH/DANIDA
National Drug Authority
Plot 93
Buganda Rd
P.O. Box 23096,Kampala, Uganda
Tel: 256-41-255665
Fax: 256-41-255758
Pharmaceutical Advisor Chris Forshaw [email protected] Mob: 075 760175
UNFPA
Commercial Plaza, 3
rd
Fl
Plot 7 Kampala Rd
P.O. Box 7184, Kampala, Uganda
Tel: 256-41-345600
Fax: 256-41-236645
Deputy Director Karl Kulessa [email protected]
Commercial Marketing Strategies
Plot 16 Seibwa Rd
Nakasero
P.O. Box 27659, Kampala, Uganda
Tel: 256-41-230283
Fax: 256-41-258678
Country Director Peter Cowley [email protected] Mob: 077418294
Social Marketing director Elizabeth Gardiner [email protected] Mob: 077431911
Logistics/MIS Manager Sarah Margiotta [email protected] Mob: 075640563
69
MSI – Uganda
Plot 1020 Kisugu, Muyenga
P.O. Box 3557, Kampala, Uganda
Tel: 256-41-267587
Fax: 256-41-268756
Project Director Judith Butagira [email protected]
The World bank
Rwenzori House
1 Lumumba Ave.
4 Nakesoro Rd/
P.O. Box 4463, Kampala, Uganda
Tel: 256-41-236825
Fax: 256-41-230092
Health Specialist Dr. Peter Okwero [email protected]
Joint Medical Stores
P.O. Box 4501, Kampala, Uganda
Tel: 256-41-266126
Fax: 256-41-267298
Manager Wim A.C. Mensink [email protected]
FPAU
Plot 2 Katego Rd.
P.O. Box 10746, Kampala, Uganda
Tel: 256-41-540658
Fax: 256-41-540657
Executive Director Paul B. Kabwa [email protected] Mob: 075 701953
Pallisa District Local Government
P.O. Box 14
Pallisa, Uganda
Tel: 40
District Director of Health
Services
Dr. Namonyo Andrew Mob: 077 441522
CARE International/Uganda
17 Mackinnon Rd.
Nakasero
P.O. Box 7280, Kampala, Uganda
Tel: 256-41-235880
Fax: 256-41-344295
Assistant Country
Director Program
Louis Alexander [email protected] Mob: 077 221103
Health/Education Sectors
Advisor
Dr. Tumwebaze Lorna
Makwate
[email protected] Mob: 077 412361
DfiD
Ruwenzori Courts
Tel: 256-41-348 728
Fax: 256-41-
Health Coordinator Ros Cooper Mob: 077 443 239
James Thornberry
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