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NIGERIA - LONG ROAD TOWARD POLIO ERADICATION

Routine immunisation in Nigeria remains weak as there are still some surveillance gaps. There is still a lack of access to certain parts of the country. Photo credit: Nigeria Health Watch

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Nigeria: The long crawl to polio eradication – Op-Ed

Editor’s Note: Today’s piece is an OpEd from renowned Virologist and Chair of Nigeria Expert Review Committee on Poliomyelitis Eradication and Routine Immunisation, Prof. Oyewole Tomori. This World Immunisation Week, he explores Nigeria’s long road towards polio eradication and gives insights into exactly how far we still have to go before we can confidently assert that Nigeria is no longer polio-endemic.

The theme for the 1995 World Health Day, on April 7, 1995, was "Target 2000 -- A World Without Polio". As part of the celebrations for the day, a lecture titled “Polio Eradication Race: Will Nigeria Finish last?”, was delivered at the Nigerian Institute for International Affairs (NIIA) Victoria Island, Lagos.

Now, 34 years later, the question is not whether Nigeria will finish last in Africa, she is already the last country in Africa to interrupt the transmission of polio, but the question now is, will she be the last to do so globally? Nigeria’s race to polio eradication has been a long and a slow obstacle race, a tortoise walk hampered by at least four self-inflicted obstacles.

First, Nigeria’s immunisation framework was erected on the sandy foundation of low coverage, a rickety edifice built with massive under-funding, uncaring attitude, casual neglect and careless abandon. Second, Nigeria began serious polio eradication activities very late – almost 20 years after the initial World Health Assembly (WHA) resolution calling for the global eradication of polio, and about 5 years to the initial eradication target of the year 2000. Third, some 16 years ago, precisely in 2003, we got diverted by the polio vaccine boycott which lasted for a little over a year, with far reaching and devastating consequences. Fourth and finally, the Boko Haram insurgency became the Achilles’ heel in Nigeria’s long and delayed finish of the polio eradication race.

While we may have gained ground over our late start and perhaps overcome the diversion of the polio vaccine boycott, the ending of the insurgency is the only thing that can see us through to the end of the race. In addition, by not addressing the issue of routine immunisation, we may somehow see off polio through unending supplementary immunisation activities but lose the big wars against other vaccine preventable diseases.

Routine immunisation in Nigeria remains weak as there are still some surveillance gaps. There is still a lack of access to certain parts of the country. Photo credit: Nigeria Health Watch

Routine Immunisation in Nigeria

The Nigerian Expanded Programme on Immunisation (EPI) was initiated in 1976 to focus on immunisation issues. It was centrally and almost autonomously managed by a national coordinator with sub-coordinators at the state and local government levels. During the military era, the selection of the coordinators was more and often based on ties rather than merit, competence, or suitability for the job. This resulted in the selection of individuals who were not best suited or qualified for the job.

Following a decade or more of lackluster performance, Nigeria reportedly attained the Universal Child Immunisation (UCI) target coverage of 80% by 1990. This was not sustained; between 1993 and 1998, immunisation coverage declined to 20 - 46% for DPT3. Several factors were responsible for poor performance of the EPI; The programme suffered from fickle political will and feeble financial commitment, leading to poor funding, inadequate service delivery, low social support and poor community involvement. All these, combined with poor programmatic leadership, meant that vaccines were poorly maintained in a national central store.

There were also logistic problems which ensured that vaccines were poorly distributed or not at all. With vaccine stock outs, and unavailability of syringes and needles in the few health facilities conducting routine immunisation services, millions of Nigerian children were unvaccinated. To stem the decline and recognizing that maintaining high immunisation coverage is a vital disease control strategy, the federal government, in 1997, restructured the EPI, renaming it the National Program for Immunization (NPI). Ten years later, following the Federal Government Health Sector Reform, the NPI was merged with the National Primary Health Care Development Agency (NPHCDA) in May 2007.

The change in name did little to improve immunisation coverage in Nigeria. The 10 years of NPI could well be described as the annus horribilis years for the children of Nigeria, and the annus mirabilis years for others who reportedly fed fat and voraciously, on funds meant to protect Nigerian children from the ravages of preventable diseases. The damage done to routine immunisation in the NPI years continues to be felt even today. According to the Nigeria MICS/ NICS 2016-2017, Nigeria attained the status of the country with the highest number of under-immunised children in the world (about 4.5 million). The country is also home to the deepest inequities in immunisation, both between geographic regions (e.g. coverage in Sokoto: 3%; Lagos: 80%), and between income quintiles (73% difference in coverage between lowest and highest quintile).

Nigeria’s Polio Eradication Initiative

It was in 1988, at the 41st World Health Assembly, that the landmark resolution (WHA 41.28) for the worldwide eradication of polio by the year 2000 was adopted. The target has been missed more than once. Nigeria did not seriously begin polio eradication activities until about 1996, by which time 15 African countries had successfully interrupted the transmission of polio and would have been declared free of polio but for Nigeria and 30 other African countries where polio transmission was at different levels of intensity. Of the 1,949 polio cases reported in Africa in 1996, Nigeria alone accounted for 942 or 48.3%. Seven years later, in 2003, 30 African countries had successfully interrupted polio transmission, that is reporting zero polio cases, while Nigeria reported 782 (83.7%) of the 934 polio cases reported in Africa.

The Polio vaccine boycott

The year 2003 was also the year that political, religious and academic leaders in Kano, Zamfara, and Kaduna states brought the immunisation campaign to a halt by calling on parents to reject the polio vaccine, and not allow their children to be vaccinated. A spokesman for the governor of Kano, was quoted as saying, “…

since September 11, (2003), the Muslim world is beginning to be suspicious of any move from the Western world… Our people have become really concerned about the polio vaccine.” Another leader of the Supreme Council for Sharia in Nigeria (SCSN), is quoted as saying that polio vaccines were “corrupted and tainted by evildoers from America and their Western allies.” He went on to say: “…. we believe that modern-day Hitlers have deliberately adulterated the oral polio vaccines with anti-fertility drugs and…viruses which are known to cause HIV and AIDS.”

This 13-month boycott, reminiscent of some of the misinformation and boycott around MMR in some other countries, was a major setback for polio eradication in Nigeria, with long lasting repercussions in and outside Nigeria. Nigeria became an exporter of polio virus to other countries. In the year of the boycott, Nigeria reported 355 polio cases. The following year, 2004, the number of polio cases reported by Nigeria was 782, more than double the figures for 2003. In 2005, Nigeria’s polio cases had ballooned to 833. Two years after the resumption of polio vaccination in the boycotting states, in 2006, the number of polio cases in Nigeria peaked at 1,144 cases, an average of almost 18 cases per day!

In other West African countries, new cases of polio originating and exported from Nigeria were reported in Benin, Burkina Faso, Cameroon, Chad, Cote d’Ivoire, Ghana, and Togo. These countries were previously free of polio. In 2005, Indonesia reported 4 cases of wild polio. Genetic analysis of the polio isolates traced the pathway of exportation from Nigeria to Chad to Sudan to Saudi Arabia to Indonesia.

“Don’t continue being a risk” – Unflattering WHA attention

The number of polio cases reported in Nigeria, dropped from the 1,144 cases in 2006 to 356 in 2007, and increased to 866 cases in 2008. That was the year Nigeria drew unflattering attention at the WHA. The Assembly came out with a resolution calling on Nigeria not to continue to be a risk to the world urging the country to reduce the risk of international spread of poliovirus by quickly stopping the outbreak in northern Nigeria. Obviously stung by the global rebuke, Nigeria got her act together and appointed a credible and competent CEO, Dr Pate, to run the NPHCDA. Soon after, there was a steady decline in the number of polio cases from 543 in 2009 to 130 in 2012. The number of polio cases had by 2014 dropped to 36, and Nigeria was looking forward to being declared polio free by 2017.

Boko Haram’s intensified insurgency
Nigeria’s hopes of attaining polio free status was dashed by the intensified activities of the Boko Haram group, when four new cases of polio were reported in July and August 2016, in residents of Jere, Gwoza and Monguno LGAs of Borno State, areas newly liberated from Boko Haram. Genetic analysis of the polio isolates confirmed that the viruses had been circulating for between 4-5 years in the inaccessible areas under Boko Haram occupation. These new findings again brought unfavourable attention to Nigeria, making the WHO Africa Regional Committee at its 66^th session in August 2016, declare the Nigerian wild polio isolations a sub-regional public health emergency for member states of the Lake Chad basin.

Since August 2016, Nigeria has not reported any case of wild polio in any of the accessible areas of Nigeria. Extra and innovative efforts are being made to reach populations in partially and totally inaccessible parts of Borno state. It is now estimated that less than 100,000 children are trapped in the inaccessible areas. By August 2019, if no wild polio virus is detected, Nigeria would have been polio-free for three years. After due consideration by the African Regional Certification Committee, of our immunisation coverage, level of AFP surveillance and existing situation in the inaccessible areas under Boko Haram occupation, the country may be considered as having finally achieved the status of interrupting wild polio transmission for the first time. There is a place for cautious optimism that by the end of 2019, Nigeria may finally be elevated to the status of a non-polio endemic country.

However, it is too early to start celebrating or begin a countdown. For two years between July 2014 and July 2016, Nigeria did not report any wild polio case, until new cases were detected among residents of recently liberated LGAs previously under Boko Haram control. We still have some areas, though largely reduced, of the country that are inaccessible for public health intervention, including polio vaccination and disease surveillance activities. Until all areas of Nigeria are accessible, there will always be some degree of reservation to asserting with full confidence that Nigeria is truly polio free.

Image credit: Nigeria Health Watch

While it is true that no wild poliovirus has been detected in Nigeria for more than two years, and no international spread of polio from Nigeria for more than four years, there are ongoing outbreaks of cVDPV2, which indicates the vulnerability to poliovirus infection in many parts of the country, including areas not previously considered at high risk of polio, such as Kwara State. In addition, Nigeria continues to have difficulties in controlling the protracted cVDPV outbreaks. Routine immunisation in Nigeria remains weak as there are still some surveillance gaps. There is still a lack of access to certain parts of the country. Experience has shown that the upsurge of polio cases in Nigeria usually follow changes in leadership of the NPHCDA, and election years when funds reportedly get diverted to political, rather than immunisation campaigns.

In 2016, we were “this close” to achieving non-polio endemic status, but missed the goal with detection of wild poliovirus in residents previously living in areas under Boko Haram influence. The current situation should caution us not to celebrate too early or begin a countdown to polio eradication in Nigeria. We are now in extra time of the second and possibly final half of the polio eradication race. We must be vigilant not to concede a late own goal before the race ends.

BIO: Prof. Oyewale Tomori is the immediate past President of the Nigerian Academy of Science with experience in virology, disease prevention and control. He was at the University of Ibadan from 1971 to 1994. He later served as the pioneer Vice Chancellor of the Redeemer’s University in Nigeria from 2004 to 2011. From 1994 to 2004, he was the virologist for the World Health Organization (WHO)’s Africa Region, establishing the African Regional Polio Laboratory Network. In 1981, he was recognized by the U.S. Centers for Disease Control and Prevention (CDC) for contributions to Lassa fever research. He has authored/co-authored over 150 scientific publications. Prof. Tomori has served or continues to serve on numerous advisory committees, including: (nationally) - Chair, Lassa Fever Steering Committee, National Laboratory Technical Working Group, Expert Working Group on Polio Eradication and Routine Immunization, etc, and (internationally)- WHO SAGE, WHO Africa Regional Polio Certification Committee, WHO Group of Experts on Yellow Fever Disease, Chairman WHO Yellow Fever Emergency Committee on International Health Regulations, GAVI Board, Vice Chair of U.S. National Academy of Medicine Global Health Risk Framework Commission, and World Bank Interagency Working Group on Financing Preparedness and Response. He is an international member of the U.S. National Academy of Medicine and currently Chair, Board Biovaccines Nigeria Ltd.

#PreventEpidemicsNaija Forum in one minute

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WHO Guideline Recommendations on Digital Health Interventions -Launch

Launch of the WHO Guideline Recommendations on Digital Health Interventions that took place in Geneva, and virtually on Webex

“WHO Guideline Recommendations on Digital Health Interventions” launch: https://www.who.int/news-room/detail/17-04-2019-who-releases-first-guideline-on-digital-health-interventions
WHO Guideline documents: http://bit.ly/digiguidelinewho
U-tube video of the launch: http://bit.ly/digilaunchwho

Description: This presentation provides an overview of the “WHO Guideline Recommendations on Digital Health Interventions.” It details the scoping process, synthesis of scientific evidence, and establishment of ten global recommendations by a WHO independent expert panel of the use of digital technology for health outcomes, that can be combined toward achieving country goals of universal health coverage.

The presentation by; Garrett Mehl, PhD, MHS Scientist, Digital Innovations and Research Department of Reproductive Health and Research, includes HRP - the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research in Human Reproduction World Health Organization, provides the details of the scope of the Guideline, and gives an overview for each specific digital health intervention as well as the implementation consideration within national information systems and digital architectures.

Additionally, the WHO Digital Health Atlas, www.digitalhealthatlas.org a free and open-source global platform for technology registration aiming to support and strengthen the value and impact of digital health investments, improve coordination, and facilitate institutionalization and scale among governments, technologists and implementers, and the donor and financing communities.

WHO encourages those who develop, use, or invest in digital technology for health to use the Digital Health Atlas as a registry to detail specific uses of digital health and scope of implementations.

The new recommendations describe ways that countries can use digital health technology, accessible via mobile phones, tablets and computers, to improve people’s health and essential services.

“Harnessing the power of digital technologies is essential for achieving universal health coverage,” says WHO Director-General Dr Tedros Adhanom Ghebreyesus. “Ultimately, digital technologies are not ends in themselves; they are vital tools to promote health, keep the world safe, and serve the vulnerable.”

Over the past two years, WHO systematically reviewed evidence on digital technologies and consulted with experts from around the world to produce recommendations on some key ways such tools may be used for maximum impact on health systems and people’s health.

One digital intervention already having positive effects in some areas is sending reminders to pregnant women to attend antenatal care appointments and having children return for vaccinations. Other digital approaches reviewed include decision-support tools to guide health workers as they provide care; and enabling individuals and health workers to communicate and consult on health issues from across different locations.

“The use of digital technologies offers new opportunities to improve people’s health,” says Dr Soumya Swaminathan, Chief Scientist at WHO. “But the evidence also highlights challenges in the impact of some interventions.”

She adds: “If digital technologies are to be sustained and integrated into health systems, they must be able to demonstrate long-term improvements over the traditional ways of delivering health services.”

For example, the guideline points to the potential to improve stock management. Digital technologies enable health workers to communicate more efficiently on the status of commodity stocks and gaps. However, notification alone is not enough to improve commodity management; health systems also must respond and take action in a timely manner for replenishing needed commodities.

“Digital interventions, depend heavily on the context and ensuring appropriate design,” warns Dr Garrett Mehl, WHO scientist in digital innovations and research. “This includes structural issues in the settings where they are being used, available infrastructure, the health needs they are trying to address, and the ease of use of the technology itself.”

For more information about the WHO guideline: mehlg@who.int and tamratt@who.int

TANZANIA IS FIRST AFRICAN COUNTRY TO REACH AN IMPORTANT MILESTONE IN THE REGULATION OF MEDICINES

TANZANIA IS FIRST AFRICAN COUNTRY TO REACH AN IMPORTANT MILESTONE IN THE REGULATION OF MEDICINES E-DRUG "http://www.afro.who.int/fr/node/10720"

Brazzaville / 10 December 2018: Tanzania is the first confirmed country in Africa to achieve a well-functioning, regulatory system for medical products according to the World Health Organization (WHO). This means that the Tanzania Food and Drug authority (TFDA) has made considerable improvements in recent years in ensuring medicines in the healthcare system are of good quality, safe and produce the intended health benefit.

“This is a major African milestone and we are very proud of Tanzania’s achievement, which we hope will inspire other countries in the region,” says Dr Matshidiso Moeti, WHO Regional Director for Africa. “Access to medicines alone, without quality assurance, is not enough. With this milestone Tanzania makes a big step towards improving the quality of its health care services.”

Medicines are used to prevent illnesses and treat diseases, helping many people to lead full and productive lives. However, if produced, stored or transported improperly, if falsified, or used incorrectly or abused, medicines can be hazardous and can lead to hospitalization and even death. For these reasons, it is important to have effective regulatory systems that also serve to promote timely access to quality medicines.

Fewer than 30% of the world’s medicines regulatory authorities are considered to have the capacity to perform the functions required to ensure medicines, vaccines and other health products actually work and do not harm patients. For that reason, WHO and African governments have intensified efforts to bolster the capacity of regulating medicines in the region.

Over the past years WHO has been supporting African countries, including Tanzania to strengthen their regulatory entities.

“The core of WHO’s work is to empower countries through support and knowledge transfer so that they can expand access to health services for their populations,” says Mariângela Simão, WHO Assistant Director General for Access to Medicines, Vaccines and Pharmaceuticals. “If countries want to improve health outcomes, they first need to ensure access to safe and quality medical products that actually work and benefit patients.”

WHO’s assessment of regulatory authorities is based on the ‘Global Benchmarking Tool’ – an evaluation tool that checks regulatory functions against a set of more than 200 indicators – such as product authorization, market surveillance and the detection of potential adverse-effects – to establish their level of maturity.

The benchmarking of Tanzanian regulatory authorities was carried out in phases by a WHO-led team of international experts. Earlier this year, WHO facilitated self-assessments and conducted a formal evaluation of the Tanzania Food and Drug Authority (TFDA) on the mainland and the Zanzibar Food and Drug Agency and required the regulatory authorities to make a number of adjustments. In the last assessment, Tanzania FDA met all indicators that define a maturity level 3 agency, the second highest on WHO’s scale and the target for regulatory systems globally.

Established in July 2003, the Tanzania FDA has come a long way to becoming a recognized leader in medicines regulation in Africa. The latest achievement means that medical doctors, pharmacists, chemists and technicians working for the regulatory authority possess the expertise and hands-on skills to evaluate medical products, prevent and counteract associated hazards and are capable of protecting the public from substandard and falsified medicines.

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Note for editors

Access to essential, high-quality, safe and effective medical products is a cornerstone of a well-functioning health care system. Regulatory authorities provide the oversight needed to ensure that medicines, vaccines and medical devices are safe and effective before registering these products for use. This function is critical in all countries and in Africa particularly, given that risky medical products easily filter through porous national borders or are sold outside official channels.

WHO’s work to strengthen African regulatory authorities has concentrated on building capacity through the transfer of knowledge and hands-on training, and by building cooperative networks that allow authorities in the same region to save resources by sharing data and workload. The more countries in the African region comply with WHO standards, the safer will be the supply of medicines and other medical products for African populations.

For archives: http://lists.healthnet.org/archive/html/e-drug/

REVIEW : OPEN ACCESS EXPANDING GLOBAL ACCESS TO ESSENTIAL MEDICINES

OPEN ACCESS EXPANDING GLOBAL ACCESS TO ESSENTIAL MEDICINES

Lukas Roth1, Daniel Bempong1, Joseph B. Babigumira2, Shabir Banoo3, Emer Cooke4, David Jeffreys5, Lombe Kasonde6, Hubert G. M. Leufkens7, John C.W. Lim8, Murray Lumpkin9, Gugu Mahlangu10, Rosanna W. Peeling11, Helen Rees12, Margareth Ndomondo-Sigonda13, Andy Stergachis14, Mike Ward4 and Jude Nwokike15*

Abstract

Access to quality-assured medical products improves health and save lives. However, one third of the world’s population lacks timely access to quality-assured medicines while estimates indicate that at least 10% of medicine in low- and middle-income countries (LMICs) are substandard or falsified (SF), costing approximately US$ 31 billion annually. National regulatory authorities are the key government institutions that promote access to quality-assured medicines and combat SF medical products but despite progress, regulatory capacity in LMICs is still insufficient.

Continued and increased investment in regulatory system strengthening (RSS) is needed. We have therefore reviewed existing global normative documents and resources and engaged with our networks of global partners and stakeholders to identify three critical challenges being faced by NRAs in LMICs that are limiting access to medical products and impeding detection of and response to SF medicines. The challenges are; implementing value-added regulatory practices that best utilize available resources, a lack of timely access to new, quality medical products, and limited evidence-based data to support post-marketing regulatory actions.

To address these challenges, we have identified seven focused strategies; advancing and leveraging convergence and reliance initiatives, institutionalizing sustainability, utilizing risk-based approaches for resource allocation, strengthening registration efficiency and timeliness, strengthening inspection capacity and effectiveness, developing and implementing risk-based post-marketing quality surveillance systems, and strengthening regulatory management of manufacturing variations.

These proposed solutions are underpinned by 13 focused recommendations, which we believe, if financed, technically supported and implemented, will lead to stronger health system and as a consequence, positive health outcomes.

Keywords: Access to essential medicines, Substandard and falsified, Regulatory system strengthening

WHO PUBLICATION: METHODS TO ANALYZE MEDICINE UTILIZATION AND EXPENDITURE

Recently published by WHO: http://www.who.int/medicines/publications/analyse_medicine_utilization_expenditure/en/

“… Analysis of medicines utilization can inform whether overall expenditure on medicines is within budget, whether particular medicines are responsible for budget over-spend or under-spend, or whether medicine use aligns with the expected and desired treatment rates. Analysis of medicine utilization can also support decision-making and be used to predict the likely effect on the budget of a potential new listing in a reimbursement list or formulary. The analyses can be used to review the effect of including medicines on the formulary, to determine if medicines are being used in accordance with their listed use, or to determine the effect of policy or regulatory changes. The analyses can also inform whether medicine use varies by region or age group.

This manual includes an overview of the governance structures and human resources required to support routine analysis of medicine utilization and expenditure. The data sources and methods that can be used to undertake the analyses are described, and examples of analyses are given. The final section of the manual includes a list of guidance documents for research on medicine utilization research, and web addresses of agencies that routinely publish reports of medicine utilization and expenditure to inform pharmaceutical policy.”

Full report downloadable at http://apps.who.int/iris/bitstream/handle/10665/274282/9789241514040-eng.pdf

WHO -GLOBAL FINANCING FACILITY, ESSENTIAL MEDICINES AND HEALTH PRODUCTS & OVERHAUL THE MEDICINE SUPPLY CHAIN

1. GLOBAL FINANCING FACILITY

World leaders pledge US$1 billion to transform health and nutrition of world’s poorest women, children and adolescents:

• Ten new investors—Burkina Faso, Côte d'Ivoire, Denmark, the European Commission, Germany, Japan, Laerdal Global Health, the Netherlands, Qatar and an anonymous donor—have joined since the launch of the Global Financing Facility replenishment. They join existing funders the Bill & Melinda Gates Foundation, Canada, MSD for Mothers, Norway, and the United Kingdom to fund the GFF to improve the health and nutrition of women, children and adolescents.

• US$1 billion pledged to the GFF Trust Fund in Oslo today is expected to link to an additional US$7.5 billion in IDA/IBRD resources for women, children and adolescents’ health and nutrition.

• Burkina Faso reaffirmed its commitment to allocating at least 15% of its annual budget to improve health; Côte d'Ivoire committed to increasing its health budget 15% annually; and Nigeria recommitted to investing US$150 million per year from its budget to sustainably finance health and nutrition of women, children and adolescents.

• US$1 billion will help the GFF partnership on the pathway toward expanding to as many as 50 countries with the greatest needs, to transform how health and nutrition are financed. Alongside other global health initiatives, this can contribute to saving and improving millions of lives by 2030.

More on the Global Financing Facility replenishment: www.globalfinancingfacility.org/replenishment

Photos for media: https://drive.google.com/drive/folders/1U54KVVy27l55D6NMNwq_X005ZQ44xU0i

2. ESSENTIAL MEDICINES AND HEALTH PRODUCTS

Recently published by WHO: http://www.who.int/medicines/publications/analyse_medicine_utilization_expenditure/en/

Full report downloadable at http://apps.who.int/iris/bitstream/handle/10665/274282/9789241514040-eng.pdf

3 OVERHAUL THE MEDICINE SUPPLY CHAIN

Given the problems in the old system, many countries have developed more scientific models.https://www.hindustantimes.com/rf/image_size_960x540/HT/p2/2018/08/28/Pictures/medical-strike_1b2a5b20-aaa5-11e8-abd2-5c322fa89f61.jpg

Traditional lines between public, private, online, and physical are starting to blur and, as a result, direct-to-home and online pharmacy models have developed more quickly in emerging markets like India than many had expected(Sonu Mehta/HT)

Health systems around the world are benefitting from recent advances in supply chain technologies to deliver essential medicines to patients more effectively. Traditional lines between public, private, online, and physical are starting to blur and, as a result, direct-to-home and online pharmacy models have developed more quickly in emerging markets like India than many had expected. A commonly used supply chain architecture for essential medicines in most developing countries has historically been bulk procurement by the national or state/provincial government and then distribution to districts and health clinics owned by the government. This approach, even when well implemented, may suffer from many problems which are linked to, among other things, multiple levels of complexity, long resupply intervals, uncertainties in financing, and diffused accountabilities. Many countries have, therefore, developed alternative supply chain models based on modern day supply chain science and technologies.