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Addressing accountability deficits in the management of essential medicines and health supplies (EMHS) in the district local governments in Uganda

Background

In 1992 when Uganda adopted decentralization, among the devolved powers was the management of services delivery, health services inclusive. Relatedly, the Government of Uganda (GoU) established the National Medical Stores (NMS) under the National Medical Stores Act (1993) as an agency under the Ministry of Health responsible for procuring, warehousing, and distributing medicines and health supplies to public health facilities in the country. Subsequently, the Ministry of Finance, Planning and Economic Development (MoFPED) established vote number 116 in the national budget under Ministry of Health through which NMS receives GoU funds to procure, warehouse, and distribute medicines and health supplies to the public health facilities. Joint Medical Store (JMS) is a sister agency to NMS; it procures, warehouses, and distributes medicines and health supplies to private-not-for profit (mainly faith-based) health facilities in the country. This article examines the accountability deficits in the management of essential medicines and health supplies (EMHS) in district local governments of Uganda and how these can be addressed.

Introduction

The Constitution and the LGs Act 1997 (with Amendment Act 2001) defines the legal mandate of the District/Municipal Councils. In the health sector, the District/Municipal Councils are responsible for Medical and Health services including: Management of general hospitals and Health Centres(HCs) in the respective catchment areas; Supervision and monitoring of the private sector; Implementation/enforcement of the various Health Acts and policies; and Delivering the Uganda National Minimum Health Care Package (UNMHCP)¹. As specified in Schedule 2 of the Local Government Act², Local Governments ( LGs) have the responsibility of delivering on the National Health Policy. These roles entail provision of medical and health services such as: hospitals, but not Regional Referral Hospitals; all Health Centres; Government facilities; Private Not for Profit (PNFP) health facilities; maternity and child welfare services; communicable disease control.The management of health commodities supply chain is an integral part of this mandate and this includes; planning and budgeting for health services delivery; supervision of health services delivery including health commodities supply chain services; medicines procurement planning, inter alia. This mandate is also stipulated in the district health supply chain management package³ which provides the scope for essential activities that are required for effective HSC management at the district level. Correspondingly, the recently launched 10-year roadmap for Government of Uganda’s health supply chain self-reliance (2022-2032)⁴;- elucidates on the national transition strategy to increase local capacity and ensure sustainability of HSC development outcomes. The implementation of the roadmap at subnational level requires districts/cities/municipalities and hospitals to strengthen the HSC leadership and governance coordination and accountability mechanisms.

Public health facilities at different levels of care- HC- II, III, IV and General Hospitals in the local governments receive essential medicines and health supplies from National Medical Stores (NMS) in six (6) delivery cycles in a year based on health facilities’ annual procurement plans and bi-monthly orders. These facilities are under the direct supervision of the district local governments.

The legal, policy and public expenditure governance framework

The health sector legal and policy frameworks emphasize the observance of principles of good governance in health services delivery including health commodities supply chain services at both national and sub-national levels⁵. These principles include among others, participation, transparency, accountability, coordination⁶, responsiveness⁷, equity, effectiveness, and efficiency⁸. These principles also resonate with the principles under the Bogere and Makaaru (2016) public expenditure governance assessment framework⁹ and other public expenditure governance studies¹⁰ which provide an understanding of the way public resources are governed by examining the interactions between the relevant actors, and how these interactions affect the outcomes of public expenditure.

The accountability frameworks provide for both horizontal and vertical accountability mechanisms in the health services delivery in Uganda at both national and sub-national levels. The purposes of accountability are threefold; control the misuse and abuse of public resources and/or authority; provide assurance that resources are used, and authority is exercised according to appropriate and legal procedures, professional standards and societal values; and support and promote improved service delivery and management through feedback and learning; the focus here is primarily on performance accountability¹¹.

Conclusion

In the context of the supply chain management of essential medicines and health supplies, the vertical accountability requires health facilities to account for Essential Medicines and Health Supplies (EMHS) management at the district level, the district local governments account for EMHS at ministries of local government, health, finance planning and economic development and other responsible Government of Uganda (GoU) agencies, while National Medical Stores is required to account for EMHS to ministry of health and ministry of finance, planning and economic development, parliament and any other responsible GoU entities. On the other hand, the horizontal accountability at sub-national level requires inter and intra departmental coordination and management of EMHS within a district local government.

Key issues

A series of on-site district, city, municipal and hospital health supply chain leadership and governance meetings conducted jointly by ACODE, Management Sciences for Health (MSH), Uganda Healthcare Federation (UHF), Ministry of Health (MoH), and Ministry of Local Government (MoLG) revealed several accountability deficits in the management of EMHS both on the side of NMS and district local governments as outlined below;

1. Inconsistent supply of EMHS. NMS misses delivery cycles for health facilities without sufficient explanation to the district local governments. Of recent, there has been rampant stock outs of EMHS in most health facilities across the country due to the failure by NMS to deliver EMHS to the health facilities as per the established delivery cycles. Most district local government do not receive sufficient explanation from NMS regarding this anomaly. It is important to note that NMS is accountable to the district local governments because it receives funds to procure and distribute medicines on behalf of the health facilities within the districts. Therefore, if NMS does not explain to the districts the anomalies surrounding medicines delivery as per the established delivery cycles, it becomes a huge accountability deficit on its side.
2. Discrepancies in supplies. Discrepancies between the health facility medicine orders vis-à-vis what NMS delivers. Although the districts and hospitals register these gaps at the health facilities and report to NMS for redress, often times, these discrepancies are not addressed at the loss of the affected health facilities.
3. Inappropriate time of delivery of drugs. NMS delivers medicines and health supplies at an inappropriate time. There are several reports in the districts that NMS last mile delivery companies deliver medicines and health supplies to health facilities beyond normal working hours – at night and sometimes over the weekends. This jeopardizes the accountability mechanism that requires NMS to notify the district, sub-county and health facility leaders about the delivery of medicines early in advance such that the concerned officials can be available (at District, Sub- County, Health facility managers, Health Unit Management Committees, Local Councils etc) to witness and verify the delivered medicines. If this does not happen, it creates room for unnecessary compromise, suspicion, and mistrust.
4. Absence of documentation in the districts on allocation of funds for EMHS. There is lack of deliberate efforts by the district leaders to track and document the annually allocated funds and their utilization for the procurement and supply of the EMHS for the health facilities within their respective districts. It was observed that some of the district leadership was not fully aware of the funds allocated to NMS to procure and distribute the medicines and health supplies for the health facilities of different levels of care in their respective districts. They were therefore uncertain whether NMS delivers medicines consistent with the nationally budgeted and allocated funds. In some districts, it was discovered that there were accumulated balances from different delivery cycles and no deliberate efforts had been made to follow-up on the balances with NMS.
5. District top leadership not involved in the annual procurement planning and budgeting for EMHS. Non-involvement of the top district leadership in the annual EMHS procurement planning processes. Annually, NMS facilitates annual procurement planning processes at the district and regional levels. The district health officers and some few members of the District Health Team (DHT) participate in this exercise. It was observed that other top district leadership such as the Chief Administrative Officer, Resident District Commissioner (RDC), District Chairperson do not participate in this exercise, neither are they briefed fully about the type and quantities of the EMHS the district planned for procurement in a given financial year. Therefore, this makes it difficult for the district top leadership to hold NMS accountable for the type and quantities of medicines in case not supplied.
6. Sub-optimal reporting of commodity consumption at the health facilities. All health facilities that receive EMHS from GoU either through NMS or Joint Medical Stores (JMS) are required to report on their monthly consumption through HMIS report - 106 section 6 as one of the accountability mechanisms for medicines use. This data is very crucial in informing the national quantification and procurement planning processes in the ministry of health. Unfortunately, some health facilities do not submit this monthly report consistently and of those who submit, the report is incomplete and therefore data is unusable. Consequently, the national quantification and procurement planning process in the ministry of health is compelled to use proxy data.

Conclusion

Increasing accountability is a key element in a wide variety of policies and reforms, from government-wide anti-corruption campaigns to national-level health system reform programmes, decentralized health service delivery at the local level, and community-based health funds. Accountability to curb abuse underlies accountability for purposes of adhering to standards and of improving performance¹². It is important that the leadership of the district local governments, NMS and JMS, adhere to the good governance principles and more particularly the principle of accountability for effective delivery of health commodities supply chain services. Each of the recently held on-site district/city/municipal and hospital health supply chain leadership and governance meetings climaxed with drawing action plans that are oriented towards improving health commodities supply chain performance and management practices in the districts. Based on these action plans, the following recommendations are made to address the above-mentioned accountability deficits in the management of EMHS in the district local governments.

Recommendations

• District local governments need to update the list of leaders at district, sub-county and health facilities (health unit management committee) and share it with NMS to always send the delivery notification messages without fail for accountability purposes but also to ensure the leaders are readily available to witness and verify delivery of the EMHS.
• District local governments need to organize regular meetings with the NMS regional staff to discuss and generate consensus on the ways to improve health commodities supply chain services in the district.
• District local governments need to deliberately track and document the annually allocated funds to NMS and their utilization rates and discuss with NMS how to plan for the unutilized funds (balances) in case they arise, in the next cycle or annual procurement planning. This will ensure value for money allocated to NMS to procure and distribute EMHS on behalf of the districts.
• District local governments need to make annual procurement planning for EMHS as participatory as possible to involve other top district leadership such as the CAO, RDC, District chairperson beyond district health officer and health facility in-charges. This will ensure that the district top leadership can hold NMS accountable on the delivery of the planned procurements of the EMHS for the district from the informed point of view.
• District local governments need to deliberately discuss health commodities supply chain issues in the management meetings such as top management, DEC, TPC, DHT as well as in the council sessions and make evidence-based decisions regarding the management of EMHS.
• District local governments need to improve coordination and communication flow mechanisms especially through regular sharing of health commodities supply chain data (stock status data) and other reports by the DHOs with other top district leadership such as the CAO, RDC, District Chairperson to inform evidence-based decisions regarding the management of EMHS in the districts.
• District local governments need to use a multi-pronged approach involving different tiers of leadership at health facility, district (DHOs, DHTs, Biostatisticians, HMIS Focal persons etc) to ensure consistent availability of accurate EMHS monthly consumption data to appropriately inform the national quantification and procurement planning processes in the ministry of health.

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