#1Global Health Supply Chain Summit ABSTRACT 81 TRACK 7 November 30, 2022 2022 Dakar, Senegal#2Global Health Supply Chain Summit Introduction The Drug Revolving Fund Scheme: A Catalytic Intervention for Improving Access to Medicines in Nigeria Mariya Saleh Technical Director, Reproductive, Maternal, Newborn, and Child Health USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project in Nigeria UNITED INTERNA SAGENCY USAID ATIONAL DEV USAID FROM THE AMERICAN PEOPLE @ghcs_summit; #globalhealth; #globalhealthsupplychain; #GHSCS 2#3Global Health Supply Chain Summit Background . Poor access to quality essential medicines contributes to Nigeria's high maternal, newborn, and child morbidity and mortality rates. In 2018, USAID, through the GHSC-PSM project began supporting the implementation of a Drug Revolving Fund (DRF) scheme in three high-need states in Nigeria - Bauchi, Kebbi, and Sokoto. The initiative aimed to improve access to lifesaving maternal and child health (MCH) medicines by addressing poor financing for medicines. Following several stakeholder engagements, the DRF was overwhelmingly selected as the intervention to improve availability of medicines. * Kebbi Sokoto Bauchi Under-5 mortality rate = 102 * Neonatal mortality rate = 34 * Infant mortality rate = 63 * MICS 2021 3#4Global Health Supply Chain Summit DRF System Design - Governance, Supply Chain Operations, and the Financial Model Legislation/policy framework Organizational & institutional structures Autonomy for all entities Governing structures at all levels Community engagement Legal Framework & Governance Financial model An effective and sustainable DRF Pricing, mark-up and its elements Cash handling, accounting for sales, accounting for receipts, accounting for payments Banking system, bank signatories & reconciliation & books of account Fund valuation statement Drugs Management System Selection, Quantification,, Procurement Warehousing, Distribution, Supply Chain Operations Inventory Management & LMIS *Internal Market Operation* Guiding Principles: Access: Availability, Affordability, Accessibility, Quality product ACTA: Anti-corruption, Transparency, Accountability Value: efficiency and value for money#5Global Health Supply Chain Summit Flow of DRF Funds and Commodities COMMODITY MOVEMENT MEDICINES PROCURED FROM LOCAL QUALITY MANUFACTURERS AND WHOLESALERS Funds for medicines procurement N DRF INITIAL CAPITAL INVESTMENT (SEED STOCK) BY USAID AND MANAGED BY DRUG MANAGEMENT AGENCY AND DRF COMMITTEE Capital Base: Commodities + Revenue CENTRAL MEDICAL STORE/ ZONAL MEDICAL STORE HEALTH FACILITY +7.5% Revenue from sales to Health Facilities +9% Revenue from sales N 18 User HEALTH INSURANCE BHCPF OOP pays total cost and the markup charged through various mechanisms REVENUE MOVEMENT DRF is a cost recovery scheme where health products (drugs and medical consumables) are sold at cost-price + plus a mark-up. Mark up Element Losses and Expiry M&E Sustenance Costs Inflation Deferrals & Exemptions#6Global Health Supply Chain Summit Phases of DRF Project Implementation There are five phases of DRF implementation 1 Diagnose The ongoing DRF activities and essential medicine supply chain strengths and challenges 2 % 888 3 4 Design Design or strengthen state-specific plans for Operationalize required Roll out Develop or strengthen Roll out DRF structures and operations across effective, systems for facilities (DRF sustainable a functional start) DRF DRF 5 о Sustain Provide light- touch support to ensure DRF sustainability#7Global Health Phase I. Diagnose Used Four Sources of Data to Measure the Strength of Supply Chain Summit State Systems Information gathered on what exists in the state Sources of insight Facility Diagnostic State stake- holder Interviews Other stake- holder Interviews Document Review Description Type 1: ~2-hour interview and observation at each of ~20 health facilities per state Type II: Readiness assessment 1-2-hour interview with 20+ central-level stakeholders (e.g., CMS/DMA staff, SPHCDA leadership, etc.) per state Observation of central-level structures / processes Report based on interview and observation Interviews with other relevant stakeholders including partners and community leaders Report based on interviews Review of any documents the state has developed (e.g., text of laws, SOPs, etc.) Sources used to evaluate the strength of what exists in the state Supply chain diagnostic tool Supply chain diagnostic tools that rate processes as weak, medium, and strong, developed in consultation with supply chain experts DRF expertise Nigerian and international DRF expert practitioners with experience across governance and operations 7#8Phase II. Design Global Health State Example – Bauchi Design Choices Supply Chain Summit By the end of its design workshop, Bauchi had aligned on 4 design choices and identified possible risks and mitigation strategies for each design choice Design choice Risks Increase in transportation costs Distribution to health facilities 舞 Decrease in staff productivity Markup to cover operational costs Single layer supply chain (CMS to HFs) Payment models HFs pay central store upfront ("cash and carry") Too little means some costs are not covered and too high makes the medicines unaffordable Difficulty accessing the central store and vice versa Stock-outs of some product lines at the central store Delayed reimbursement by health insurance agency 8#9Phase III. Operationalization Global Health Major Technical Assistance Nodal Points Each state has four major interactions during this phase A. Quantification exercise Weeklong multistakeholder activity to quantify the stock (MNCH and essential medicines) required in each state B. Capacity Building Development of SOPs, followed by comprehensive capability-building rollout covering State Governance Committees, Central Medical Stores and health facilities. Modules include DRF Operations, Governance, Supply Chain Operations and Financial Management C. CMS & Facility upgrade verification Verification of the readiness of all eligible facilities and Central Medical Stores > D. Seed stock release Seed stock to be released to Central Medical Stores and relevant Health Facilities#10Readiness for DRF Global Health Roll-out in the Three States Supply Chain Summit I. Facility assessment & selection 2. Inauguration of governance structures • State Level (including functional DMA) Facility Level 3. Development/Amendment of DMA law 4. Upgrade of health facilities and CMS 5. Opening of DRF Accounts 6. Development of SOPs 7. Capitalization with seed stock Bauchi Sokoto Kebbi -- 8. Monitoring and Evaluation Each state will complete 8 major activities to ensure that adequate systems are in place for the DRF Completed In progress Delayed Not yet started 10#11Global Health Supply Chain Summit Phase IV. DRF Roll-out DRF training Alignment with the government's primary health care revitalization strategy Site activation Category trained Total Trained Bauchi # of health facilities trained # personnel trained 323 PHC (100%) 3,400 25 SHF (100%) Total Trained Sokoto 99 PHC (40%) 1,474 24 SHF (100%) Total trained 4874 Overall (F- 1,444) - Seed stock capitalization (M-3,430) - Tools deployment Onsite mentoring Supportive systems strengthening interventions (sustainability) Procurement technical assistance • Warehouse operations • Support for state-led distribution • Linkage to QA manufacturers and suppliers Supervision • Monitoring and evaluation#12Global Health Supply Chain Summit Phase V: Sustain DRF Operations Supervision, Data Flow and Reporting Timelines </> O 8 Health Facility Data Collection and Validation 1st 8th LGA Essential Drug Officer Electronic data entry 8th-12th Board - HMB/SPHCDA Agency level data aggregation and summary 12th-16th In-State Team State level data aggregation and report preparation 16th - 20th State DRF Steering Committee Quarterly DRF Steering Committee Meeting for key governance and policy decision making State DRF Committee Monthly DRF review meeting for report finalization and decision making 25th - 28th SUBMIT#13Global Health Supply Chain Summit Loss & Expiry vs Physical Expiry Value Loss & Expiry (Mark-Up Value for the Month) #438,031.19 Physical Expiry Value #1,083,576.44 #0.00 #400,000.00 #800,000.00 #1,200,000.00 13#14Global Health Supply Chain Summit . . Conclusions Overall, the availability of medicines improved significantly; it is higher in DRF facilities compared with facilities not implementing the DRF. Through a comprehensive system strengthening approach, the DRF scheme is increasing transparency and accountability in the management of medicines at all levels within each of the states. • With careful execution of the five stages of the DRF, the Nigerian government can sustain the initiative • If sustained, the improved availability of lifesaving commodities will reduce preventable maternal, newborn, and child deaths in Nigeria. @ghcs_summit; #globalhealth; #globalhealthsupplychain; #GHSCS 14#15Global Health Supply Chain Summit You can find more information on the Drug Revolving Fund (DRF) scheme implementation on our website: https://www.ghsupplychain.org/drug-revolving-funds-drf-playbook 15#16Global Health Supply Chain Summit The USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project is funded under USAID Contract No. AID-OAA-I-15-0004. GHSC-PSM connects technical solutions and proven commercial processes to promote efficient and cost- effective health supply chains worldwide. Our goal is to ensure uninterrupted supplies of health commodities to save lives and create a healthier future for all. The project purchases and delivers health commodities, offers comprehensive technical assistance to strengthen national supply chain systems, and provides global supply chain leadership UNITED STATES USAID NATIONAL AGENCY ELOPMENT USAID FROM THE AMERICAN PEOPLE USAID Global Health Supply Chain Program- Procurement and Supply Management (GHSC-PSM) project in Nigeria 16#17Global Health Supply Chain Summit Thank you to our sponsors Chemonics Development works here. M ✓ Technology & Operations Ross School of Business - UNIVERSITY OF MICHIGAN ROSS HELP K LOGISTICS Logenix International, L.L.C. USC Marshall School of Business MEBS GLOBAL KBR PICMA @ghcs_summit; #globalhealth; #globalhealthsupplychain; #GHSCS WILLIAM DAVIDSON INSTITUTE AT THE UNIVERSITY OF MICHIGAN SYSTEMS FOR DEVELOPMENT WHERE TRANSFORMATION STARTS 17