By Amy Dempsey and Saumya RamaRao
The global health community knows how to prevent women from dying during pregnancy, delivery, and postpartum. The science that describes what works and what does not is out there, and as dissemination channels increase in number more people are learning about it. This is a positive trend for women – especially those of reproductive age – in low-income countries (LICs), where they are 300 times more likely to die from pre-eclampsia and eclampsia (PE/E) than women in high-income countries.
Despite the uptake of knowledge sharing, actually putting proven, low-cost interventions into practice is not increasing at the same rate. But why? One reason is that too often good quality, life-saving medicines and equipment do not exist at the point of care. In LICs, strong health systems are hard to come by. A strong health system has many moving parts, each one supporting the functionality and efficacy of another.
The World Health Organization defined six building blocks of a well-oiled health system – health service delivery, health workforce, health information systems, access to essential medicines, health systems financing, and leadership and governance.
This blog focuses on access to essential medicines – product and supply chains – and how it impacts PE/E-related maternal health outcomes. This matters because globally, deaths associated with PE/E are the second leading cause of maternal mortality, largely because antihypertensive drugs, calcium supplements, aspirin, magnesium sulphate (MgSO4), and calcium gluconate are not in facilities or pharmacies when providers and women need them.
Poor supply chains exist for many reasons. This includes everything from poor warehousing and storage of essential products, weak logistics including transport to the point of care, and limited capacity for forecasting and quantification so that orders for medicines can be put in on time.
But all these problems have a solution. For example, implementing storage and distribution guidelines can maintain the integrity of a life-saving medicine. Increasing accessibility of health products means that providers and pharmacists must know how to accurately quantify the demand for a product. If they order more than what is needed, the cost of drugs expiring on the shelf is high and adds to cost inefficiencies. Training in quantification and forecasting and easy to use tools can circumvent this problem of over or under-supply.
Agrawal et al. advocates for outsourcing health supply chain logistics to private providers for more effective systems. Citing Senegal, Kenya, South Africa, Nigeria, Zimbabwe, and Togo as successful private sector delivery systems, she says outsourcing would mean more competition, which would improve performance. In this context, outsourcing does not mean looking to foreign providers for health system management, it merely means that management would take place outside the traditional public health infrastructure. These outsourced private providers receive incentives for adhering to rigid quality assurance and storage guidelines. They are better equipped to manage growth, and they have better data and information management system.
An associated issue is poor-quality medicines — they can be ineffective and even harmful. This happens because Ministries of Health often procure medicines and drugs from manufacturers who may not meet international quality assurance standards. These commodities may have a lower bid than other manufacturers, but even the cheapest medicine may in fact be more expensive due to problems with its formulation. It might not have the proper measurements of pharmaceutical ingredients or it may have impurities mixed in. When this happens, the procurer purchases a medicine with the wrong formulation, lessening its effectiveness. And then there are market issues. Markets need to be shaped, and in LICs, attracting manufacturers to produce high-quality, affordable medicines is key.
If all these problems are solved and a high-quality medicine ends up in a health facility, it might still be inaccessible to the patients who need it. Health providers may not know it exists, or they may not be trained on its proper use. Bad water and roads, and inconsistent electricity also impact whether a medicine can be administered to a patient.
High-functioning supply chains – whether publicly or private managed – can and do have a positive impact for all women in LICs. For pregnant women who experience PE/E, a strong supply chain means she is likely to receive proper, timely treatment. That makes a difference between life and death, for a mother and her baby.